Healthcare Provider Details

I. General information

NPI: 1972957512
Provider Name (Legal Business Name): THERESA ELAINE BOURNE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA ELAINE NEIDERER M.D.

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 06/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8821 COLUMBIA 100 PKWY
COLUMBIA MD
21045-2274
US

IV. Provider business mailing address

8821 COLUMBIA 100 PKWY
COLUMBIA MD
21045-2274
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-1700
  • Fax: 410-740-8315
Mailing address:
  • Phone: 410-997-1700
  • Fax: 410-740-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD86548
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: