Healthcare Provider Details

I. General information

NPI: 1710981105
Provider Name (Legal Business Name): THOMAS R. BORTHWICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N STATE OF FRANKLIN RD SUITE 24
JOHNSON CITY TN
37604-6089
US

IV. Provider business mailing address

408 N STATE OF FRANKLIN RD SUITE 24
JOHNSON CITY TN
37604-6089
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-1810
  • Fax: 423-431-1811
Mailing address:
  • Phone: 423-431-1810
  • Fax: 423-431-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD12631
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: