Provider Demographics
NPI:1164480679
Name:BOURLAND, MARY EVELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:EVELYN
Last Name:BOURLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2708 RIFE MEDICAL LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-3888
Mailing Address - Fax:479-338-4453
Practice Address - Street 1:2708 RIFE MEDICAL LN
Practice Address - Street 2:SUITE 210
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:479-338-3888
Practice Address - Fax:479-338-4453
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE43552086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122998001Medicaid
AR122998001Medicaid
AR5N191Medicare ID - Type Unspecified