MEDICARE: MR. STEVEN C BOURGEOIS MA, CCC-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	AUD003412	GA

General Provider Information

NPI Number	:	1053399345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEVEN C BOURGEOIS MA, CCC-A

Provider Business Mailing Address
First Line	:	2026 OAK TREE TRL
Second Line	:
City	:	LAKE VILLA
State	:	IL
Zip	:	60046-7566
Country	:	US
Telephone Number	:	847-331-4669
Fax Number	:	413-647-4096

Provider Business Practice Location Address
First Line	:	1020 11TH AVE
Second Line	:
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-3102
Country	:	US
Telephone Number	:	847-688-5568
Fax Number	:	847-688-4430

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	07/08/2007

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