Provider Demographics
NPI:1689641649
Name:BORISSOVA, IRINA V (MD, PHD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:V
Last Name:BORISSOVA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT. OF ANESTHESIOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5900
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT. OF ANESTHESIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5900
Practice Address - Fax:601-984-5939
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1268207L00000X, 207LP3000X, 208000000X
MS21550207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197750601Medicaid
MS06276558Medicaid
MS302I050811OtherMEDICARE PTAN
TXN1268OtherSTATE LICENSE
TX197750605Medicaid
TX197750606OtherCSHCN
I12744Medicare UPIN
MS06276558Medicaid