MEDICARE: DR. MICHAEL WILLIAM BOURNE DO

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	207RC0000X	Cardiovascular Disease Physician	338054	NY

General Provider Information

NPI Number	:	1710546965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL WILLIAM BOURNE DO

Provider Business Mailing Address
First Line	:	440 W 114TH ST STE 220
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-1796
Country	:	US
Telephone Number	:	212-523-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 W 114TH ST STE 220
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-1796
Country	:	US
Telephone Number	:	212-523-4000
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	05/25/2026

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