Provider Demographics
NPI:1487090718
Name:BOURNAY, TARA D (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:BOURNAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:A
Other - Last Name:DELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3601 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8151
Mailing Address - Country:US
Mailing Address - Phone:231-946-1120
Mailing Address - Fax:231-946-8943
Practice Address - Street 1:3601 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8151
Practice Address - Country:US
Practice Address - Phone:231-946-1120
Practice Address - Fax:231-946-8943
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900001556OtherPRIORITY HEALTH