Provider Demographics
NPI:1609947159
Name:BOUC, GEOFFREY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:THOMAS
Last Name:BOUC
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 1:3005 RIVERSIDE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1500
Mailing Address - Country:US
Mailing Address - Phone:608-365-7200
Mailing Address - Fax:608-365-7202
Practice Address - Street 1:3005 RIVERSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1500
Practice Address - Country:US
Practice Address - Phone:608-365-7200
Practice Address - Fax:608-365-7202
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32161500Medicaid
000054009Medicare ID - Type Unspecified
WI32161500Medicaid