Healthcare Provider Details

I. General information

NPI: 1891782447
Provider Name (Legal Business Name): EDGAR AMISTOSO BORDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3046 N ASHLAND AVENUE
CHICAGO IL
60657-3034
US

IV. Provider business mailing address

3046 N ASHLAND AVENUE
CHICAGO IL
60657-3034
US

V. Phone/Fax

Practice location:
  • Phone: 773-528-5851
  • Fax: 773-528-9790
Mailing address:
  • Phone: 773-528-5851
  • Fax: 773-528-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: