Provider Demographics
NPI:1669428603
Name:BOUGHNER, BRICE T (MD)
Entity type:Individual
Prefix:DR
First Name:BRICE
Middle Name:T
Last Name:BOUGHNER
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 3239
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3239
Mailing Address - Country:US
Mailing Address - Phone:844-295-4871
Mailing Address - Fax:
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-381-1111
Practice Address - Fax:931-552-6663
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS185522085R0202X
TN444522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN30027211Medicaid
TNP00687770OtherRAILROAD MEDICARE
TN30027211Medicaid
TNH91880Medicare UPIN
TN30027211Medicare PIN