Healthcare Provider Details

I. General information

NPI: 1710546965
Provider Name (Legal Business Name): MICHAEL WILLIAM BOURNE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-606-1004
  • Fax:
Mailing address:
  • Phone: 401-444-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberLP06913
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: