Provider Demographics
NPI:1477666436
Name:BOUSLOG, GERALD (PT)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:BOUSLOG
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-282-7219
Mailing Address - Fax:515-282-7213
Practice Address - Street 1:604 LOCUST ST
Practice Address - Street 2:SUITE 210
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3705
Practice Address - Country:US
Practice Address - Phone:515-282-7019
Practice Address - Fax:515-282-7213
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0475145Medicaid
IAQ47838Medicare UPIN
IA0475145Medicaid