Healthcare Provider Details

I. General information

NPI: 1881644912
Provider Name (Legal Business Name): BORLAND GROOVER CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-7205
  • Fax: 904-265-6409
Mailing address:
  • Phone: 904-398-3262
  • Fax: 904-265-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE ETZKORN
Title or Position: EXECUTIVE VP OF OPERATIONS
Credential: MD
Phone: 904-398-7205