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General NPI Number Information
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NPI Number | 1114410875
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Entity Type | Individual
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Provider Name | MIKHAIL MIKHAILOVICH GORBOUNOV MD
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Gender | Male
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Dates
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Enumeration Date | 06/07/2018
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Last Update Date | 07/08/2024
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Provider Practice Location Address
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Address Line | 593 EDDY ST
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City | PROVIDENCE
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State | RI
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Zip | 02903-4923
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Country | US
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Telephone | 401-444-5057
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Fax | 401-606-1233
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Provider Business Mailing Address
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Address Line | 593 EDDY ST
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City | PROVIDENCE
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State | RI
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Zip | 02903-4923
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Country | US
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Telephone | 401-444-5057
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Fax | 401-606-1233
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZH0000X
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Taxonomy Name | Hematology (Pathology) Physician
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License Number | A-177937
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207ZP0007X
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Taxonomy Name | Molecular Genetic Pathology (Pathology) Physician
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License Number | A-177937
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | MD19925
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License Number State | RI
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