Provider Demographics
NPI:1427198639
Name:BORDERS, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BORDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 HUNTERS GLN
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8688
Mailing Address - Country:US
Mailing Address - Phone:270-824-9630
Mailing Address - Fax:270-824-9630
Practice Address - Street 1:546 HUNTERS GLN
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-8688
Practice Address - Country:US
Practice Address - Phone:270-824-9630
Practice Address - Fax:270-824-9630
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1005409168247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000111564OtherANTHEM BLUE CROSS
KY86054012Medicaid