Provider Demographics
NPI:1336138288
Name:BOURDEAU, BRIAN JOSEPH (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:BOURDEAU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 CORTEZ RD W
Mailing Address - Street 2:STE 100
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3167
Mailing Address - Country:US
Mailing Address - Phone:941-739-7828
Mailing Address - Fax:941-739-7838
Practice Address - Street 1:3651 CORTEZ RD W
Practice Address - Street 2:STE 100
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3167
Practice Address - Country:US
Practice Address - Phone:941-739-7828
Practice Address - Fax:941-739-7838
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2288818OtherAETNA PROVIDER
FLY909JOtherBCBS PROVIDER
FLK3420Medicare ID - Type UnspecifiedMCR GROUP PROVIDER
FLU4895AMedicare UPIN