1457342842 NPI number — MICHAEL BOURGEOIS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457342842 NPI number — MICHAEL BOURGEOIS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BOURGEOIS

Provider First Name:

MICHAEL

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1457342842

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/03/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 5865

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

LUBBOCK

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

79408-5865

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

806-743-2898

Provider Business Mailing Address Fax Number:

806-743-2787

Provider First Line Business Practice Location Address:

4102 24TH ST STE 507

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LUBBOCK

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

79410-1805

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

806-743-7334

Provider Business Practice Location Address Fax Number:

806-743-7332

Provider Enumeration Date:

11/03/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208M00000X , with the licence number:  F5842 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2080P0205X , with the licence number: F5842 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 460001727 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: A119 . This is a "TRIWEST" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
• Identifier: 138369704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: V2944 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
• Identifier: 100086010B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
• Identifier: 36233 . This is a "PRESBYTERIAN COMMERCIAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
• Identifier: 108958105 . This is a "FIRSTCARE COMMERCIAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 138369711 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 36233 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
• Identifier: 89C152 . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 80822Z . This is a "HMO BLUE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".