Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 029964 | CT |
N | 208600000X | Surgeon | 029964 | CT |
Y | 2086S0120X | Pediatric Surgery | 029964 | CT |
NPI | 1518939321 |
---|---|
Provider Name | Michael Bourque |
First Address | Hartford, CT 06106-3322 |
Second Address | Hartford, CT 06106-3322 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2006 |
Last Update Date | 04/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001299644 | (05) | CT |
E32401 | (02) | CT |