1578688560 NPI number — MRS. LYDIA CORNELL BOURKE N.P.

Table of content: MRS. LYDIA CORNELL BOURKE N.P. (NPI 1578688560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578688560 NPI number — MRS. LYDIA CORNELL BOURKE N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURKE
Provider First Name:
LYDIA
Provider Middle Name:
CORNELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORNELL
Provider Other First Name:
LYDIA
Provider Other Middle Name:
WOOD
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578688560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
472 LINCOLN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE POINTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48230-1609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-299-9850
Provider Business Mailing Address Fax Number:
248-299-9860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2494 S ROCHESTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48307-3817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-299-9850
Provider Business Practice Location Address Fax Number:
248-299-9860
Provider Enumeration Date:
03/20/2007

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: 163WM0705X , with the licence number:  4704215985 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 4704215985 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5008670700 . This is a "BCBS INDIVIDUAL #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4704215985 . This is a "NURSE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5187136 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4704215985 . This is a "NURSE PRACTITIONER LICEN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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