Healthcare Provider Details

I. General information

NPI: 1578068961
Provider Name (Legal Business Name): ALEXANDER ROBERT BOREHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

200 MULLINS DR
LEBANON OR
97355-3983
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7170
  • Fax: 304-388-6597
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3921
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: