Provider Demographics
NPI:1598846891
Name:THAD A . BOURQUE, M.D. APMC
Entity Type:Organization
Organization Name:THAD A . BOURQUE, M.D. APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAD
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-234-5554
Mailing Address - Street 1:913 S COLLEGE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3060
Mailing Address - Country:US
Mailing Address - Phone:337-234-5554
Mailing Address - Fax:
Practice Address - Street 1:913 S COLLEGE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3060
Practice Address - Country:US
Practice Address - Phone:337-234-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty