Basic Information
| Provider Information | |||||||||
| NPI: | 1063602431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURGEOIS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | MOORE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2012 POINTE SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707915426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252020946 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8212 SUMMA AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257694403 | ||||||||
| FaxNumber: | 2257693842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD.202681 | LA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 2011-00769 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1000892 | 05 | LA | MEDICAID |