Healthcare Provider Details

I. General information

NPI: 1174772354
Provider Name (Legal Business Name): SCOTT A BORUCHOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 WILSON PARKE AVE STE 150
AUSTIN TX
78726-4061
US

IV. Provider business mailing address

6210 E HWY 290 STE 240
AUSTIN TX
78723-1144
US

V. Phone/Fax

Practice location:
  • Phone: 737-247-7200
  • Fax: 512-406-7368
Mailing address:
  • Phone: 512-483-9596
  • Fax: 512-406-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberP5598
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number236439
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number236439
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: