Healthcare Provider Details

I. General information

NPI: 1700882776
Provider Name (Legal Business Name): ROBERT BRUCE BORUCKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/20/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 HAMPTON ST
COLUMBIA SC
29201
US

IV. Provider business mailing address

3321 FOREST DRIVE SUITE 4
COLUMBIA SC
29204
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-1511
  • Fax: 803-256-7333
Mailing address:
  • Phone: 803-661-9519
  • Fax: 803-661-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number013376
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number13376
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: