=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245419118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CECIL M. BOURNE, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2007
-----------------------------------------------------
Last Update Date | 10/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 S ALAMEDA ST SUITE 306
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78411-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-852-4200
-----------------------------------------------------
Fax | 361-852-5304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 S ALAMEDA ST SUITE 306
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78411-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-852-4200
-----------------------------------------------------
Fax | 361-852-5304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CECIL MARTINDALE BOURNE
-----------------------------------------------------
Credential | MD, FACP
-----------------------------------------------------
Telephone | 361-852-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D8154
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------