1124082375 NPI number — DR. DIANE A BOURKE M.D.

Table of content: DR. DIANE A BOURKE M.D. (NPI 1124082375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124082375 NPI number — DR. DIANE A BOURKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURKE
Provider First Name:
DIANE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124082375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHENECTADY RD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-782-3700
Provider Business Mailing Address Fax Number:
518-782-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7B JOHNSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-782-7733
Provider Business Practice Location Address Fax Number:
518-782-0800
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X , with the licence number:  173530 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 173530 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 042ZE1 . This is a "EMPIRE BLUECROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 143257 . This is a "GHI/HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5780670 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9042526 . This is a "MVP HELATHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01820997 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 091231000203 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PRC110027743 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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