Provider Demographics
NPI:1699769869
Name:BOUCHER, RENE ALBERT (DO)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:ALBERT
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 PARK ST
Mailing Address - Street 2:STE 203 B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1784
Mailing Address - Country:US
Mailing Address - Phone:270-393-1912
Mailing Address - Fax:270-393-1913
Practice Address - Street 1:165 NATCHEZ TRACE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7940
Practice Address - Country:US
Practice Address - Phone:270-282-2024
Practice Address - Fax:270-393-1913
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY02561207L00000X, 207LP2900X, 208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64980105Medicaid
KYF55027Medicare UPIN
KY64980105Medicaid