MEDICARE: BRANDON ELLIOTT BOURGEOUS MD

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	207V00000X	Obstetrics & Gynecology Physician	34399	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669476602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON ELLIOTT BOURGEOUS MD

Provider Business Mailing Address
First Line	:	788 8TH AVE SE
Second Line	:	SUITE 100
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52401-2107
Country	:	US
Telephone Number	:	319-363-2682
Fax Number	:	319-363-1473

Provider Business Practice Location Address
First Line	:	788 8TH AVE SE
Second Line	:	SUITE 100
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52401-2107
Country	:	US
Telephone Number	:	319-363-2682
Fax Number	:	319-363-1473

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	12/27/2011

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