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General NPI Number Information
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NPI Number | 1588683718
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Entity Type | Individual
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Provider Name | GLEN BORDAK M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 3801 SPRING ST
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City | RACINE
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State | WI
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Zip | 53405-1667
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Country | US
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Telephone | 262-687-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 1055 PRAIRIE DR # D
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City | RACINE
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State | WI
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Zip | 53406-3971
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Country | US
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Telephone | 262-898-7100
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Fax | 262-898-7171
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 27568-020
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License Number State | WI
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