Provider Demographics
NPI:1578054995
Name:BOURGEOIS, ROBERT GIBSON
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GIBSON
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BELDALE RD
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-9656
Mailing Address - Country:US
Mailing Address - Phone:518-369-1421
Mailing Address - Fax:
Practice Address - Street 1:1855 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5026
Practice Address - Country:US
Practice Address - Phone:518-369-1421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000043691237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist