1164409348 NPI number — JEFFERY R BOURGERIE O.D.

Table of content: JEFFERY R BOURGERIE O.D. (NPI 1164409348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164409348 NPI number — JEFFERY R BOURGERIE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURGERIE
Provider First Name:
JEFFERY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164409348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 E BROADWAY AVE
Provider Second Line Business Mailing Address:
P.O. BOX 547
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54451-1835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-748-2020
Provider Business Mailing Address Fax Number:
715-748-4565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54451-1835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-748-2020
Provider Business Practice Location Address Fax Number:
715-748-4565
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2228 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38715300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37815100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39-1229699 . This is a "FEDERAL TAX ID-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391229699015 . This is a "BLUE CROSS BLUE SHIELD-ME" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 0474980001 . This is a "DMERC-MEDFORD GROUP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 10445 . This is a "NVA-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 410045063 . This is a "RAILROAD MEDICARE-COLBY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1271670001 . This is a "DMERC-COLBY GROUP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 21143 . This is a "SECURITY HEALTH PLAN-MEDF" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 2228 . This is a "LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39-1967186 . This is a "FEDERALTAX ID-COLBY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38581200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391967186091 . This is a "BLUE CROSS BLUE SHIELD-CO" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 410015253 . This is a "RAILROAD MEDICARE-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 63857 . This is a "SECURITY HEALTH PLAN-COLB" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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