Provider Demographics
NPI:1669436796
Name:BOULET, JOHN G (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:BOULET
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 11407
Mailing Address - Street 2:DRAWER 0314
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0314
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:EM DEPT
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4421
Practice Address - Country:US
Practice Address - Phone:256-265-9905
Practice Address - Fax:256-265-9910
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.27888207P00000X
TXG3171207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558705Medicaid
AL4134776OtherAETNA
AL009943232Medicaid
AL051004447OtherBCBS
AL4134776OtherAETNA
AL051558705Medicare PIN