Healthcare Provider Details

I. General information

NPI: 1114410875
Provider Name (Legal Business Name): MIKHAIL MIKHAILOVICH GORBOUNOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
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: 401-444-5057
  • Fax: 401-606-1233
Mailing address:
  • Phone: 401-444-5057
  • Fax: 401-606-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA-177937
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License NumberA-177937
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD19925
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: