Basic Information
| Provider Information | |||||||||
| NPI: | 1306810759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 851417 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366851417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423000 | ||||||||
| FaxNumber: | 2513423043 | ||||||||
| Practice Location | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SPRINGHILL MEDICAL CENTER ANESTHESIA DEPT | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423000 | ||||||||
| FaxNumber: | 2513423043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 03/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1074276 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000051288 | 05 | AL | MEDICAID | 105570 | 05 | AL | MEDICAID | CN0216 | 01 | AL | MEDICARE TRAVELERS | OTHER |