Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YP0228X | Pediatric Otolaryngology | 039054 | GA |
NPI | 1306800404 |
---|---|
Provider Name | Dr. Jack C Borders JR. |
First Address | Augusta, GA 30901-2603 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2006 |
Last Update Date | 17/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000617801B | (05) | GA |
000617801F | (05) | GA |