Healthcare Provider Details

I. General information

NPI: 1871596064
Provider Name (Legal Business Name): GENE A BOURGASSER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 N 1000 W
LINTON IN
47441-5013
US

IV. Provider business mailing address

1185 N 1000 W
LINTON IN
47441-5282
US

V. Phone/Fax

Practice location:
  • Phone: 812-847-4481
  • Fax:
Mailing address:
  • Phone: 812-847-4481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01030642
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: