MEDICARE: DR. LORELEI NATASHA BOURLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	62057	CO
2	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	DR.0062057	CO
3	207K00000X	Allergy & Immunology Physician	304556	NY

General Provider Information

NPI Number	:	1144649260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORELEI NATASHA BOURLA M.D.

Provider Business Mailing Address
First Line	:	3044 ROUTE 50
Second Line	:
City	:	SARATOGA SPRINGS
State	:	NY
Zip	:	12866-3073
Country	:	US
Telephone Number	:	518-886-5814
Fax Number	:

Provider Business Practice Location Address
First Line	:	3044 ROUTE 50
Second Line	:
City	:	SARATOGA SPRINGS
State	:	NY
Zip	:	12866-3073
Country	:	US
Telephone Number	:	518-886-5814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	09/16/2020

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