Provider Demographics
NPI:1659342152
Name:BORK, MICHAEL D (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BORK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 FORT STREET
Mailing Address - Street 2:SUITE D ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-8895
Practice Address - Fax:734-324-3404
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010520207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382791823OtherTAX ID
MI0H24657OtherBLUE CROSS
MIF67493OtherUPIN
MIQ24657062Medicare PIN
MIP022140Medicare PIN
MIF67493OtherHAP ID
F67493Medicare UPIN
MI024657062Medicare PIN
MIQ24657009Medicare PIN
MI5337130OtherAETNA
MI1992725352OtherGRP NPI
MI4792733Medicaid
MI4944648Medicaid