MEDICARE: MR. MICHAEL CHARLES BOURGEOIS CRNA

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	183500000X	Pharmacist	19119	TX
2	183500000X	Pharmacist	009868L	LA
3	367500000X	Certified Registered Nurse Anesthetist	501613	TX
4	367500000X	Certified Registered Nurse Anesthetist	RN051202	LA

General Provider Information

NPI Number	:	1871585901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL CHARLES BOURGEOIS CRNA

Provider Business Mailing Address
First Line	:	31003 SHERRIE LN
Second Line	:
City	:	MAGNOLIA
State	:	TX
Zip	:	77354-5793
Country	:	US
Telephone Number	:	281-460-3120
Fax Number	:	281-259-0879

Provider Business Practice Location Address
First Line	:	31003 SHERRIE LN
Second Line	:
City	:	MAGNOLIA
State	:	TX
Zip	:	77354-5793
Country	:	US
Telephone Number	:	281-460-3120
Fax Number	:	281-259-0879

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	08/10/2010

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