Basic Information
| Provider Information | |||||||||
| NPI: | 1083616940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURGEOIS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | SIDNEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12915 KEDLESTON CIRCLE | ||||||||
| Address2: | |||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2398263578 | ||||||||
| FaxNumber: | 2399316125 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 WINKLER EXTENSION | ||||||||
| Address2: | |||||||||
| City: | FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399393939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME34882 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 373863900 | 05 | FL | MEDICAID |