Basic Information
| Provider Information | |||||||||
| NPI: | 1275907867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSERVE PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2939 KENNY RD STE 200 | ||||||||
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| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402745000 | ||||||||
| FaxNumber: | 4407168608 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 W MAIN ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430549225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149399110 | ||||||||
| FaxNumber: | 6419394857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | BOURLAND | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 61493989110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.