Provider Demographics
NPI:1043494479
Name:EBON ANTHONY BOURNE MD PA
Entity Type:Organization
Organization Name:EBON ANTHONY BOURNE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EBON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-895-8240
Mailing Address - Street 1:2595 WEDDINGTON RIDGE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068
Mailing Address - Country:US
Mailing Address - Phone:954-895-8240
Mailing Address - Fax:678-504-5346
Practice Address - Street 1:2594 WEDDINGTON RDG NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2283
Practice Address - Country:US
Practice Address - Phone:954-895-8240
Practice Address - Fax:678-504-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84326207R00000X
GA68373261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265092400Medicaid
FLH63877Medicare UPIN
FL265092400Medicaid