Provider Demographics
NPI:1245419118
Name:CECIL M. BOURNE, MD
Entity Type:Organization
Organization Name:CECIL M. BOURNE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:MARTINDALE
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:361-852-4200
Mailing Address - Street 1:3301 S ALAMEDA ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1882
Mailing Address - Country:US
Mailing Address - Phone:361-852-4200
Mailing Address - Fax:361-852-5304
Practice Address - Street 1:3301 S ALAMEDA ST
Practice Address - Street 2:SUITE 306
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1882
Practice Address - Country:US
Practice Address - Phone:361-852-4200
Practice Address - Fax:361-852-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8154207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081210901Medicaid
TX110184080OtherMEDICARE RAILROAD
82N381OtherBCBS
TX110184080OtherMEDICARE RAILROAD
TX00823KMedicare PIN
TX081210901Medicaid