Healthcare Provider Details

I. General information

NPI: 1134536584
Provider Name (Legal Business Name): HEALTHSERVE PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 ROCKY FORK BLVD
GAHANNA OH
43230-3336
US

IV. Provider business mailing address

2939 KENNY RD STE 200
COLUMBUS OH
43221-2406
US

V. Phone/Fax

Practice location:
  • Phone: 614-442-2431
  • Fax: 614-442-2426
Mailing address:
  • Phone: 614-274-5035
  • Fax: 440-716-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL C BOURLAND
Title or Position: PRESIDENT
Credential:
Phone: 614-442-2431