Provider Demographics
NPI:1700883477
Name:BOURGANOS, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BOURGANOS
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 1:68 CUMBERLAND ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-3323
Mailing Address - Country:US
Mailing Address - Phone:401-762-3838
Mailing Address - Fax:401-762-8252
Practice Address - Street 1:68 CUMBERLAND ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3323
Practice Address - Country:US
Practice Address - Phone:401-762-3838
Practice Address - Fax:401-762-8252
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10285174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008247Medicaid
RI069006280Medicare PIN
RIH14279Medicare UPIN
RI7008247Medicaid
RI007060801Medicare PIN
RI007056216Medicare ID - Type Unspecified