Healthcare Provider Details

I. General information

NPI: 1902916778
Provider Name (Legal Business Name): BRIAN BAHMAN BORG MD, MHSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1159
JACKSON MS
39216-4609
US

IV. Provider business mailing address

971 LAKELAND DR STE 1159
JACKSON MS
39216-4609
US

V. Phone/Fax

Practice location:
  • Phone: 769-251-5674
  • Fax: 769-243-8130
Mailing address:
  • Phone: 769-251-5674
  • Fax: 769-243-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number22079
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD 0059992
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2023026998
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License NumberMD.202825
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number202825
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number2023026998
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number22079
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: