Ebon Anthony Bourne MD PA

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

License

68373 Issued in GA

Legal business name

EBON ANTHONY BOURNE MD PA

Practice address

2594 Weddington RDG NE
Marietta, GA 30068-2283

Phone

(954) 895-8240

Fax

(678) 504-5346

NPI assigned

Dec 20, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Ebon Anthony Bourne, MD

Title

MD/Owner

Phone

(954) 895-8240

Specialties & licenses 2

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1198108800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1426809600000",
    "number": "1043494479",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2595 WEDDINGTON RIDGE",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "30068",
            "telephone_number": "954-895-8240",
            "fax_number": "678-504-5346"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2594 WEDDINGTON RDG NE",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300682283",
            "telephone_number": "954-895-8240",
            "fax_number": "678-504-5346"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EBON ANTHONY BOURNE MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-20",
        "last_updated": "2015-03-20",
        "status": "A",
        "authorized_official_last_name": "BOURNE",
        "authorized_official_first_name": "EBON",
        "authorized_official_middle_name": "ANTHONY",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "954-895-8240",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "FL",
            "license": "ME84326",
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "GA",
            "license": "68373",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "265092400",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Multi-Specialty Clinic/Center in Marietta, GA
• Providers in Marietta, GA by specialty
• Multi-Specialty Clinic/Center in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 20, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.