Provider Demographics
NPI:1710546965
Name:BOURNE, MICHAEL WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:BOURNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:THE GW MEDICAL FACULTY ASSOCIATES
Mailing Address - Street 2:2150 PENNSYLVANIA AVENUE, NW
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037
Mailing Address - Country:US
Mailing Address - Phone:202-741-3000
Mailing Address - Fax:
Practice Address - Street 1:THE GW MEDICAL FACULTY ASSOCIATES
Practice Address - Street 2:2150 PENNSYLVANIA AVENUE, NW
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037
Practice Address - Country:US
Practice Address - Phone:202-741-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine