Provider Demographics
NPI:1386988004
Name:HEALTHSERVE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:HEALTHSERVE MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOURLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-442-2431
Mailing Address - Street 1:2939 KENNY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2406
Mailing Address - Country:US
Mailing Address - Phone:614-442-2431
Mailing Address - Fax:614-442-2426
Practice Address - Street 1:445 ROCKY FORK BLVD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3336
Practice Address - Country:US
Practice Address - Phone:614-442-2431
Practice Address - Fax:614-442-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH245100Medicare PIN