Basic Information
| Provider Information | |||||||||
| NPI: | 1699769869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 PARK ST | ||||||||
| Address2: | STE 203 B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703931912 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 NATCHEZ TRACE AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702822024 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 09/18/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 02561 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 02561 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 02561 | KY | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0000X | 02561 | KY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64980105 | 05 | KY | MEDICAID |