Provider Demographics
NPI:1528074309
Name:JAMES C. BOUDREAU, DPM, SC
Entity type:Organization
Organization Name:JAMES C. BOUDREAU, DPM, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:414-425-5140
Mailing Address - Street 1:6191 S. 108TH ST.
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130
Mailing Address - Country:US
Mailing Address - Phone:414-425-5140
Mailing Address - Fax:414-425-7960
Practice Address - Street 1:6191 S. 108TH ST.
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130
Practice Address - Country:US
Practice Address - Phone:414-425-5140
Practice Address - Fax:414-425-7960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI349025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43260100Medicaid
WIT61539Medicare UPIN
WI000184024Medicare PIN