Provider Demographics
NPI:1811946767
Name:BOURHILL, IAN L (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:L
Last Name:BOURHILL
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 1:205 E MAIN ST STE 1-6
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-7930
Mailing Address - Country:US
Mailing Address - Phone:631-424-4026
Mailing Address - Fax:866-427-7103
Practice Address - Street 1:205 E MAIN ST STE 1-6
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7930
Practice Address - Country:US
Practice Address - Phone:631-424-4026
Practice Address - Fax:631-424-4046
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1901752086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG08524Medicare UPIN
NY1023F1Medicare ID - Type UnspecifiedMEDICARE ID#