MEDICARE: HEALTHSERVE PRIMARY CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QP2000X	Physical Therapy Clinic/Center
2	363L00000X	Nurse Practitioner
3	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1134536584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSERVE PRIMARY CARE, LLC

Provider Business Mailing Address
First Line	:	2939 KENNY RD STE 200
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-2406
Country	:	US
Telephone Number	:	614-274-5035
Fax Number	:	440-716-8608

Provider Business Practice Location Address
First Line	:	445 ROCKY FORK BLVD
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-3336
Country	:	US
Telephone Number	:	614-442-2431
Fax Number	:	614-442-2426

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL C BOURLAND
Credential	:
Telephone Number	:	614-442-2431

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	07/17/2014

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