1477739852 NPI number — DR. ALLAN NEAL BORUSZAK MD

Table of content: DR. ALLAN NEAL BORUSZAK MD (NPI 1477739852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477739852 NPI number — DR. ALLAN NEAL BORUSZAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORUSZAK
Provider First Name:
ALLAN
Provider Middle Name:
NEAL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1477739852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4466 WILDRYE DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHPORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28461-8683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-239-3131
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MCLEOD DILLON HOSPITAL
Provider Second Line Business Practice Location Address:
301 E. JACSON ST
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-777-5091
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2008

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: 207V00000X , with the licence number:  200400818 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89137M4 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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