Provider Demographics
NPI:1396969226
Name:NICOLE H. BOUDREAU,MD P.C.
Entity type:Organization
Organization Name:NICOLE H. BOUDREAU,MD P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:HURLEY
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-232-0440
Mailing Address - Street 1:1180 BEACON ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3885
Mailing Address - Country:US
Mailing Address - Phone:617-232-0440
Mailing Address - Fax:617-232-8444
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-232-0440
Practice Address - Fax:617-232-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205483207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0108197Medicaid
MAA31311Medicare ID - Type Unspecified
MA0108197Medicaid