Provider Demographics
NPI:1548245913
Name:BOUR, ERIC STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:STEVEN
Last Name:BOUR
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 1:1010 PRINCE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5805
Mailing Address - Country:US
Mailing Address - Phone:706-353-1630
Mailing Address - Fax:
Practice Address - Street 1:1010 PRINCE AVE STE 300
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5805
Practice Address - Country:US
Practice Address - Phone:706-425-1470
Practice Address - Fax:706-425-1471
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA079719208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2489Medicaid
SC576007863190OtherBCBS OF SC
SCP00378890OtherRR MEDICARE
SCP00378890OtherRR MEDICARE
SCGP2489Medicaid
SC576007863190OtherBCBS OF SC