Provider Demographics
NPI:1316030661
Name:EL-BORNO, BASSAM MA (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:MA
Last Name:EL-BORNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 BLUESTONE DR
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-6900
Mailing Address - Country:US
Mailing Address - Phone:717-560-9811
Mailing Address - Fax:
Practice Address - Street 1:160 N POINTE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4134
Practice Address - Country:US
Practice Address - Phone:717-560-5600
Practice Address - Fax:717-560-5955
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042960E2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001263220Medicaid
PA001263220Medicaid
PA665875Medicare ID - Type Unspecified