Basic Information
| Provider Information | |||||||||
| NPI: | 1790751667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132845308 | ||||||||
| FaxNumber: | 4132845413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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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 | 207P00000X | 000446 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 78416 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.