Basic Information
| Provider Information | |||||||||
| NPI: | 1669896239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSERVE PRIMARY CARE LLC | ||||||||
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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: | 5263 NIKE STATION WAY | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430267449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148762100 | ||||||||
| FaxNumber: | 6148762120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2014 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOURLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6144422431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT008883 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 363LA2200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1535534 | 01 | OH | STATE LICENSE | OTHER |