Basic Information
Provider Information | |||||||||
NPI: | 1457342842 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOURGEOIS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5865 | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794085865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067432898 | ||||||||
FaxNumber: | 8067432787 | ||||||||
Practice Location | |||||||||
Address1: | 4102 24TH ST STE 507 | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794101805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067437334 | ||||||||
FaxNumber: | 8067437332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 12/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | F5842 | TX | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 2080P0205X | F5842 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
ID | Type | State | Issuer | Description | 460001727 | 01 | TX | RAILROAD | OTHER | A119 | 01 | NM | TRIWEST | OTHER | 138369704 | 05 | TX |   | MEDICAID | V2944 | 05 | NM |   | MEDICAID | 100086010B | 05 | OK |   | MEDICAID | 36233 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 108958105 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 138369711 | 05 | TX |   | MEDICAID | 36233 | 05 | NM |   | MEDICAID | 89C152 | 01 | TX | BC/BS | OTHER | 80822Z | 01 | TX | HMO BLUE | OTHER |