Healthcare Provider Details

I. General information

NPI: 1053362442
Provider Name (Legal Business Name): ERIC C BOUREKAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 10TH AVE
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

700 ACKERMAN RD SUITE 270
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-8315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number35065107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: