Provider Demographics
NPI:1710169479
Name:BOURGEOIS FAMILY MEDICINE CLINIC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BOURGEOIS FAMILY MEDICINE CLINIC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:BARROW
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-276-6018
Mailing Address - Street 1:1409 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-4407
Mailing Address - Country:US
Mailing Address - Phone:337-276-6018
Mailing Address - Fax:337-276-9507
Practice Address - Street 1:1409 CHURCH ST
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-4407
Practice Address - Country:US
Practice Address - Phone:337-276-6018
Practice Address - Fax:337-276-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017806261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DC13Medicare PIN