Healthcare Provider Details

I. General information

NPI: 1417042979
Provider Name (Legal Business Name): CHARLES D BORUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 JEFFERSON DAVIS BLVD. SUITE F
NATCHEZ MS
39120
US

IV. Provider business mailing address

131 JEFFERSON DAVIS BLVD. SUITE F
NATCHEZ MS
39120
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-0200
  • Fax: 601-445-0210
Mailing address:
  • Phone: 601-442-0200
  • Fax: 601-445-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10244
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: