Basic Information
| Provider Information | |||||||||
| NPI: | 1902885320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURN | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021131 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206692500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 04-30337 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1000641970A | 05 | KS | MEDICAID |