Provider Demographics
NPI:1184780272
Name:KERGOSIEN, GEOFFREY GAINES (PT)
Entity type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:GAINES
Last Name:KERGOSIEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 MITTEER DR
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-8905
Mailing Address - Country:US
Mailing Address - Phone:228-466-5679
Mailing Address - Fax:
Practice Address - Street 1:833 HIGHWAY 90
Practice Address - Street 2:SUITE 2
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1601
Practice Address - Country:US
Practice Address - Phone:228-463-9030
Practice Address - Fax:228-463-0103
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist