Basic Information
| Provider Information | |||||||||
| NPI: | 1992700967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULTER | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 PLEASANT ST. | ||||||||
| Address2: | YEAPLE BUILDING | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032287200 | ||||||||
| FaxNumber: | 6032287307 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PLEASANT ST. | ||||||||
| Address2: | YEAPLE BUILDING | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032287200 | ||||||||
| FaxNumber: | 6032287307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4811 | NH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 371516 | 01 | NH | MVP HEALTHCARE | OTHER | 3016636 | 01 | NH | AETNA | OTHER | 2553 | 01 | NH | CIGNA | OTHER | H005016 | 01 | NH | TRICARE | OTHER | 361 | 05 | NH | MEDICAID | D78744 | 01 | NH | HARVARD PILGRIM HEALTHCAR | OTHER |