1659506400 NPI number — BOURN AND ASSOCIATES, P.C.

Table of content: (NPI 1659506400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659506400 NPI number — BOURN AND ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOURN AND ASSOCIATES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1659506400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 NAVAJO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62711-6084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-741-2315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 WESTGATE DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62711-7066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-303-8600
Provider Business Practice Location Address Fax Number:
217-303-5950
Provider Enumeration Date:
05/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BOURN
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-303-8600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046-008999 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1851340152 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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