Provider Demographics
NPI:1972957512
Name:BOURNE, THERESA ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ELAINE
Last Name:BOURNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ELAINE
Other - Last Name:NEIDERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8821 COLUMBIA 100 PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2274
Mailing Address - Country:US
Mailing Address - Phone:410-997-1700
Mailing Address - Fax:410-740-8315
Practice Address - Street 1:8821 COLUMBIA 100 PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2274
Practice Address - Country:US
Practice Address - Phone:410-997-1700
Practice Address - Fax:410-740-8315
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD86548208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics