Provider Demographics
NPI:1013995554
Name:BORUCKI, GREGORY S (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:BORUCKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6568
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35824-0568
Mailing Address - Country:US
Mailing Address - Phone:256-325-4075
Mailing Address - Fax:
Practice Address - Street 1:124 BLUFF SPRING DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7386
Practice Address - Country:US
Practice Address - Phone:256-325-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-719207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA-1381-06OtherLICENSE
NMCS00211972OtherCONTROLLED SUBSTANCE
ALDO-719OtherLICENSE
ALBB5959094OtherDEA CERT NUMBER
ALH27486Medicare UPIN