Provider Demographics
NPI:1679617757
Name:KELLY BOURGEOIS M.D.
Entity type:Organization
Organization Name:KELLY BOURGEOIS M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-580-9030
Mailing Address - Street 1:PO BOX 73265
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77273-3265
Mailing Address - Country:US
Mailing Address - Phone:281-580-9030
Mailing Address - Fax:281-580-2725
Practice Address - Street 1:427 WEST 20TH #102
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008
Practice Address - Country:US
Practice Address - Phone:281-580-9030
Practice Address - Fax:281-580-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9190207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty