Basic Information
| Provider Information | |||||||||
| NPI: | 1962806570 | ||||||||
| 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: | 445 ROCKY FORK BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432303336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144422431 | ||||||||
| FaxNumber: | 6144422426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2014 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOURLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6144422431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 153534 | 01 | OH | BUSINESS LICENSE | OTHER |