Provider Demographics
NPI:1023103439
Name:BOULAY, BRIAN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:BOULAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 N SHERIDAN RD
Mailing Address - Street 2:APT 504
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5493
Mailing Address - Country:US
Mailing Address - Phone:802-356-7432
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:UIC MEDICAL CENTER, SECTION OF DIGESTIVE DISEASES
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-0199
Practice Address - Country:US
Practice Address - Phone:312-355-4270
Practice Address - Fax:312-996-5103
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13031207RG0100X
CAA107914207RG0100X
IL036.125568207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology