Provider Demographics
NPI:1942291893
Name:BORK, RANDY M (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:M
Last Name:BORK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:1254 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1343
Practice Address - Country:US
Practice Address - Phone:810-664-4531
Practice Address - Fax:810-667-7337
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA201542OtherMCLAREN HEALTH PLAN
MI4133944OtherAETNA
MIE26538OtherHEALTH ALLIANCE PLAN
MI0854432194OtherBLUE CROSS BLUE SHIELD
MI3303639Medicaid
MIE26538OtherFEDERAL HEALTH SERVICES
MI0832195OtherHEALTH PLUS
MIC1516OtherMCARE
MI201542OtherHEALTH ADVANTAGE NETWORK
MI4133944OtherAETNA
MI0M28430Medicare ID - Type Unspecified