Basic Information
| Provider Information | |||||||||
| NPI: | 1538698212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | JEFFERY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076214680 | ||||||||
| FaxNumber: | 2076224085 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076214680 | ||||||||
| FaxNumber: | 2076224085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | TL6435 | CO | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | DO3299 | ME | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.