Basic Information
| Provider Information | |||||||||
| NPI: | 1821422486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSERVE MEDICAL GROUP 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: | 2939 KENNY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144422431 | ||||||||
| FaxNumber: | 6144422426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2013 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOURLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6144422431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1535531 | 01 | OH | STATE REGISTRATION | OTHER |