Healthcare Provider Details

I. General information

NPI: 1710979778
Provider Name (Legal Business Name): VIDAL D BORROMEO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W BIG BEAVER RD STE. 130
BLOOMFIELD HILLS MI
48304-3909
US

IV. Provider business mailing address

5505 WING LAKE RD
BLOOMFIELD HILLS MI
48301-1250
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-7355
  • Fax: 248-644-6840
Mailing address:
  • Phone: 248-626-0829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberVB031765
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: