Provider Demographics
NPI:1821422486
Name:HEALTHSERVE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:HEALTHSERVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-442-2431
Mailing Address - Street 1:2939 KENNY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2406
Mailing Address - Country:US
Mailing Address - Phone:614-442-2431
Mailing Address - Fax:614-442-2426
Practice Address - Street 1:2939 KENNY RD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2406
Practice Address - Country:US
Practice Address - Phone:614-442-2431
Practice Address - Fax:614-442-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1535531OtherSTATE REGISTRATION