Provider Demographics
NPI:1548292519
Name:BOURN, MICHAEL V (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
Last Name:BOURN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5368 STOCKTON CT
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8602
Mailing Address - Country:US
Mailing Address - Phone:614-598-6588
Mailing Address - Fax:
Practice Address - Street 1:1161 BETHEL RD STE 203
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2773
Practice Address - Country:US
Practice Address - Phone:614-459-0350
Practice Address - Fax:614-456-0355
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4435-B207P00000X
OH34.007735207PH0002X, 207RA0401X, 208VP0014X
OH61-218472083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2320401Medicaid
OH2320401Medicaid
NDH59392Medicare UPIN