Healthcare Provider Details

I. General information

NPI: 1710471024
Provider Name (Legal Business Name): DANIEL AARON BORMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 300
GRAND RAPIDS MI
49503-2527
US

IV. Provider business mailing address

330 BARCLAY AVE NE STE 300
GRAND RAPIDS MI
49503-2527
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax: 616-391-8897
Mailing address:
  • Phone: 616-391-8810
  • Fax: 616-391-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301115760
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: