Healthcare Provider Details

I. General information

NPI: 1275900656
Provider Name (Legal Business Name): CHRISTOPHER BOURGET CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY MEDICAL PLAZA SUITE 205
MOUNT VERNON IL
62864-2408
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY
MOUNT VERNON IL
62864-2402
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-1108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209013864
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number183149
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number183149
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: