1295735751 NPI number — DR. FREDERICK WILLIAM BORN D.O.

Table of content: DR. FREDERICK WILLIAM BORN D.O. (NPI 1295735751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295735751 NPI number — DR. FREDERICK WILLIAM BORN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORN
Provider First Name:
FREDERICK
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295735751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4077 S CLEVELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-429-2992
Provider Business Mailing Address Fax Number:
269-429-3372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4077 S CLEVELAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-429-2992
Provider Business Practice Location Address Fax Number:
269-429-3372
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  510 100 9712 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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