Basic Information
Provider Information | |||||||||
NPI: | 1548292519 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOURN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | V | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5368 STOCKTON CT | ||||||||
Address2: |   | ||||||||
City: | POWELL | ||||||||
State: | OH | ||||||||
PostalCode: | 430658602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145986588 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1161 BETHEL RD STE 203 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432202773 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144590350 | ||||||||
FaxNumber: | 6144560355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 05/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34-00-4435-B | OH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207PH0002X | 34.007735 | OH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine | 207RA0401X | 34.007735 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 208VP0014X | 34.007735 | OH | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2083A0300X | 61-21847 | OH | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 2320401 | 05 | OH |   | MEDICAID |