Basic Information
| Provider Information | |||||||||
| NPI: | 1124082375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURKE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 7B JOHNSON RD | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187827733 | ||||||||
| FaxNumber: | 5187820800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 173530 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 174400000X | 173530 | NY | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 042ZE1 | 01 | NY | EMPIRE BLUECROSS | OTHER | 143257 | 01 | NY | GHI/HMO | OTHER | 5780670 | 01 | NY | AETNA | OTHER | 9042526 | 01 | NY | MVP HELATHCARE | OTHER | 01820997 | 05 | NY | MEDICAID | 091231000203 | 01 | NY | FIDELIS | OTHER | PRC110027743 | 01 | NY | CDPHP | OTHER |