Provider Demographics
NPI:1558301655
Name:BORISSOVA, IRINA (MD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BORISSOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PROFESSIONAL VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:LADYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1569
Mailing Address - Country:US
Mailing Address - Phone:843-524-6829
Mailing Address - Fax:843-524-5820
Practice Address - Street 1:12 PROFESSIONAL VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:LADYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29907-1569
Practice Address - Country:US
Practice Address - Phone:843-524-6829
Practice Address - Fax:843-524-5820
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG89690Medicare UPIN