=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114237351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER BORCHARDT, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2010
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 BROWNSTONE WAY #107
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-679-2470
-----------------------------------------------------
Fax | 201-300-4384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 648
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-0648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-679-2470
-----------------------------------------------------
Fax | 201-300-4384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROGER BORCHARDT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 201-679-2470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | 25MA08749100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------