Healthcare Provider Details

I. General information

NPI: 1255394227
Provider Name (Legal Business Name): BRYSON DALE BORG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4357 THE MASTERS DR
FAIRFIELD CA
94533-9514
US

IV. Provider business mailing address

23625 COMMERCE PARK STE 204
BEACHWOOD OH
44122-5845
US

V. Phone/Fax

Practice location:
  • Phone: 855-292-1401
  • Fax: 866-396-8340
Mailing address:
  • Phone: 216-255-5700
  • Fax: 216-255-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35082726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: