Chanell Raven Bourne, MD
Individual provider Active NPI Student in an Organized Health Care Education/Training Program · Providence, RI
NPI 1356089775 · NPPES record last updated May 25, 2022
Key facts
- NPI
- 1356089775
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Student in an Organized Health Care Education/Training Program 390200000X
- License
- LP05536 (RI)
- Practice address
- 593 Eddy St
Providence, RI 02903-4923 - Phone
- (401) 444-5180
- NPI assigned
- May 25, 2022
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: No · DME: Yes · Home health: No · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20241017002599 | MA | Order and Referring Only - General Surgery |
0446638225 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | LP05536 | RI | Yes |
Addresses
Primary practice location
593 Eddy St
Providence, RI 02903-4923
Mailing address
593 Eddy St
Providence, RI 02903-4923
Other providers in Providence, RI
- Cathy Bour
- Claire Dorothy Bourgault
- Siobhan Bourget
- Lizette Bouris
- Ghada Bourjeily
- Mary Bernadette Bourne
- Michael William Bourne
- Kristen Laurie Bourque
- Meredith Ealise Bourque
- Julie Anne Bousquet-Eulie
All providers in Providence, RI · Student in an Organized Health Care Education/Training Program in Rhode Island
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 25, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.