MEDICARE: DR. THOMAS CLEMENT BORUT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	G25587	CA

General Provider Information

NPI Number	:	1528104064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS CLEMENT BORUT M.D.

Provider Business Mailing Address
First Line	:	563 36TH ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-3409
Country	:	US
Telephone Number	:	310-215-1600
Fax Number	:	310-215-0783

Provider Business Practice Location Address
First Line	:	6033 W CENTURY BLVD
Second Line	:	#200
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-6410
Country	:	US
Telephone Number	:	310-215-1600
Fax Number	:	310-215-0783

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	11/12/2009

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