Provider Demographics
NPI:1447306568
Name:BOURG, SIDNEY PAUL (PT)
Entity type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:PAUL
Last Name:BOURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:SID
Other - Middle Name:
Other - Last Name:BOURG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:127 BARRILLEAUX ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:LA
Mailing Address - Zip Code:70374-2548
Mailing Address - Country:US
Mailing Address - Phone:985-532-7399
Mailing Address - Fax:985-632-3581
Practice Address - Street 1:5550 N HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:LA
Practice Address - Zip Code:70374-2000
Practice Address - Country:US
Practice Address - Phone:985-532-6800
Practice Address - Fax:985-532-6813
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT00536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist