Basic Information
Provider Information | |||||||||
NPI: | 1194768994 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAFF | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | BOURKE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4500 13TH ST | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012494282 | ||||||||
FaxNumber: | 6012494852 | ||||||||
Practice Location | |||||||||
Address1: | 1506 ASTON AVE | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012494282 | ||||||||
FaxNumber: | 6012494852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 05/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD025787 | TN | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 19880 | MS | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 08585290 | 05 | MS |   | MEDICAID |