Provider Demographics
NPI:1659385979
Name:BOROUGHS, SAMANTHA LYN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:LYN
Last Name:BOROUGHS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3639
Mailing Address - Country:US
Mailing Address - Phone:706-507-3332
Mailing Address - Fax:706-507-3359
Practice Address - Street 1:400 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3639
Practice Address - Country:US
Practice Address - Phone:706-507-3332
Practice Address - Fax:706-507-3359
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA54794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA457935967AMedicaid
GA457935967AMedicaid
GAI21217Medicare UPIN
GA11SCDKFMedicare ID - Type Unspecified