Basic Information
| Provider Information | |||||||||
| NPI: | 1386988004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSERVE MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | EXPRESSMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2939 KENNY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144422431 | ||||||||
| FaxNumber: | 6144422426 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 ROCKY FORK BLVD | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432303336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144422431 | ||||||||
| FaxNumber: | 6144422426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOURLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6144422431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.