Provider Demographics
NPI:1164412649
Name:BOURNE, MICHAEL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:BOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-275-3325
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI746213ES0103X, 213E00000X
MN445213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN164225100Medicaid
WI43222300Medicaid
MNU20784Medicare UPIN
MN480000529Medicare PIN
MN164225100Medicaid
WI000856150Medicare PIN