Provider Demographics
NPI:1225178825
Name:BOURNE, EBON ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:EBON
Middle Name:ANTHONY
Last Name:BOURNE
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 1:1100 JOHNSON FY RD NE STE 190
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1733
Mailing Address - Country:US
Mailing Address - Phone:404-419-9970
Mailing Address - Fax:404-252-8930
Practice Address - Street 1:1100 JOHNSON FY RD NE STE 190
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-1733
Practice Address - Country:US
Practice Address - Phone:404-419-9970
Practice Address - Fax:404-252-8930
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068373207R00000X
GA68373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68373OtherLICENSE
FLH63877Medicare UPIN
FL265092400Medicaid