Provider Demographics
NPI:1609813773
Name:BORCHARDT, MARC (CRNA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BORCHARDT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 W BROOK DR SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-3671
Mailing Address - Country:US
Mailing Address - Phone:706-291-9570
Mailing Address - Fax:
Practice Address - Street 1:501 REDMOND RD NW
Practice Address - Street 2:ANESTHESIOLOGY DEPARTMENT
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1415
Practice Address - Country:US
Practice Address - Phone:706-291-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN131448367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000815944GMedicaid
GAP00211515OtherRAILROAD GEORGIA
GA000815944HMedicaid
GA43BBBGLMedicare ID - Type UnspecifiedMEDICARE
GA000815944HMedicaid