=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154304996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY M BORKAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2005
-----------------------------------------------------
Last Update Date | 04/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 BREWSTER ST FAMILY CARE CENTER
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-729-2769
-----------------------------------------------------
Fax | 401-729-2772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 BREWSTER ST WOOD BLDG 516
-----------------------------------------------------
City | PAWTUCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02860-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-729-3481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD10711
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------