MEDICARE: MICHAEL D BORK DO

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	207V00000X	Obstetrics & Gynecology Physician	5101010520	MI
2	207VM0101X	Maternal & Fetal Medicine Physician	5101010520	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	382791823	OTHER	MI	TAX ID
2	0H24657	OTHER	MI	BLUE CROSS
3	F67493	OTHER	MI	UPIN

General Provider Information

NPI Number	:	1659342152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D BORK DO

Provider Business Mailing Address
First Line	:	1640 FORT STREET
Second Line	:	SUITE D ATTN DENISE
City	:	TRENTON
State	:	MI
Zip	:	48183
Country	:	US
Telephone Number	:	734-391-3057
Fax Number	:	734-391-3052

Provider Business Practice Location Address
First Line	:	2333 BIDDLE AVE
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-4668
Country	:	US
Telephone Number	:	734-246-8895
Fax Number	:	734-324-3404

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	02/21/2017

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