Healthcare Provider Details

I. General information

NPI: 1811946767
Provider Name (Legal Business Name): IAN L BOURHILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E MAIN ST STE 1-6
HUNTINGTON NY
11743-7930
US

IV. Provider business mailing address

205 E MAIN ST STE 1-6
HUNTINGTON NY
11743-7930
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-4026
  • Fax: 631-424-4046
Mailing address:
  • Phone: 631-424-4026
  • Fax: 866-427-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number190175
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: