Provider Demographics
NPI:1972536282
Name:BOURGEOIS, BLAISE (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:
Last Name:BOURGEOIS
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:FEGAN 9
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-2413
Mailing Address - Fax:617-730-0463
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FEGAN 9
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-2413
Practice Address - Fax:617-730-0463
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1565982080A0000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3183271Medicaid
MAA32836Medicare ID - Type Unspecified
MAF14337Medicare UPIN