MEDICARE: MICHAEL HAL BOURNE JR. MD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	12857513-1205	UT
2	207RP1001X	Pulmonary Disease Physician	12857513-1205	UT

General Provider Information

NPI Number	:	1881030443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL HAL BOURNE JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 741729
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-1729
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 E 3900 S STE 4050
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1264
Country	:	US
Telephone Number	:	801-266-3418
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	06/11/2024

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