Provider Demographics
NPI:1851462394
Name:WILLIAM E, BOURGEOIS O.D,, S.C.
Entity Type:Organization
Organization Name:WILLIAM E, BOURGEOIS O.D,, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPOA
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HERBST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-735-9593
Mailing Address - Street 1:1507 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1301
Mailing Address - Country:US
Mailing Address - Phone:715-735-9593
Mailing Address - Fax:
Practice Address - Street 1:1507 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1301
Practice Address - Country:US
Practice Address - Phone:715-735-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI022713001OtherADMINISTAR
WI022713001OtherADMINISTAR
WI87-484Medicare ID - Type Unspecified
WI0227130001Medicare NSC