Basic Information
| Provider Information | |||||||||
| NPI: | 1871596064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURGASSER | ||||||||
| FirstName: | GENE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1185 N 1000 W | ||||||||
| Address2: | |||||||||
| City: | LINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474415282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128474481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 N 1000 W | ||||||||
| Address2: | |||||||||
| City: | LINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474415013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128474481 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01030642 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100210220B | 05 | IN | MEDICAID | 200015680A | 05 | IN | MEDICAID |