Provider Demographics
NPI:1154519213
Name:GIRGIS, BAHAA BOLOUS (MD)
Entity type:Individual
Prefix:
First Name:BAHAA
Middle Name:BOLOUS
Last Name:GIRGIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16258 BRIGHT MORNING CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-0500
Mailing Address - Country:US
Mailing Address - Phone:951-352-2421
Mailing Address - Fax:
Practice Address - Street 1:9194 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3802
Practice Address - Country:US
Practice Address - Phone:951-352-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64665207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH08412Medicare UPIN
CA00A646650Medicare PIN