Provider Demographics
NPI:1922030808
Name:BOUCHER, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10583
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0583
Mailing Address - Country:US
Mailing Address - Phone:251-435-2646
Mailing Address - Fax:251-435-6478
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-435-2646
Practice Address - Fax:251-435-6478
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16746207PE0004X
ALMD.16746207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51533347OtherBLUE CROSS
AL51003502OtherBLUE CROSS
AL000098517Medicaid
AL51098517OtherBLUE CROSS
AL009936088Medicaid
AL009936091Medicaid
AL009936089Medicaid
AL51533346OtherBLUE CROSS
AL51098517OtherBLUE CROSS
ALF43703Medicare UPIN
AL009936091Medicaid