Basic Information
| Provider Information | |||||||||
| NPI: | 1508830522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOU-HARB | ||||||||
| FirstName: | TALAL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015622621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088853025 | ||||||||
| FaxNumber: | 5088854090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 80602 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 043058466002 | 01 | TRICARE | OTHER | 110166307 | 01 | RAILROAD MEDICARE | OTHER | 784247 | 01 | MVP HEALTH CARE | OTHER | AA1196 | 01 | HARVARD PILGRIM HLTHCARE | OTHER | J16105 | 01 | BLUE SHIELD HMO BLUE | OTHER | 5098641 | 01 | CIGNA HEALTH PLAN | OTHER | J16105 | 01 | BLUE SHIELD INDEMNITY | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYST | OTHER | J16105 | 01 | BLUE CARE ELECT | OTHER | 043058466 | 01 | HEALTHCARE VALUE MGMT | OTHER | 872046 | 01 | FIRST HEALTH | OTHER | 0401738 | 01 | EVERCARE | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 2017162 | 01 | US HEALTHCARE | OTHER | 3137201 | 05 | MA | MEDICAID | 042472266 | 01 | ONE HEALTH PLAN | OTHER | 2017162 | 01 | AETNA | OTHER | 33751 | 01 | FALLON COMM. HEALTH PLAN | OTHER |