Healthcare Provider Details

I. General information

NPI: 1548292519
Provider Name (Legal Business Name): MICHAEL V BOURN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 BETHEL RD STE 203
COLUMBUS OH
43220-2773
US

IV. Provider business mailing address

5368 STOCKTON CT
POWELL OH
43065-8602
US

V. Phone/Fax

Practice location:
  • Phone: 614-459-0350
  • Fax: 614-456-0355
Mailing address:
  • Phone: 614-598-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34-00-4435-B
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number34.007735
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number34.007735
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number34.007735
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number61-21847
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: