Provider Demographics
NPI:1629507124
Name:GOUGIS, BRYAN P
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:P
Last Name:GOUGIS
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 1:279 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-1716
Mailing Address - Country:US
Mailing Address - Phone:773-209-1968
Mailing Address - Fax:888-858-7372
Practice Address - Street 1:3440 171ST PL
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323-2807
Practice Address - Country:US
Practice Address - Phone:888-858-7372
Practice Address - Fax:888-858-7372
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15-013746-1372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201352780AMedicaid