Provider Demographics
NPI:1134170590
Name:BORN, ROBERT J (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BORN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8300
Mailing Address - Fax:
Practice Address - Street 1:1802 S. MATTIS AVENUE
Practice Address - Street 2:ORTHOPEDICS
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-383-7676
Practice Address - Fax:217-383-4910
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003180213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-003180Medicaid
IL0533210001OtherDMERC
T37573Medicare UPIN
ILK17320Medicare PIN
ILT37573Medicare UPIN
IL0533210001OtherDMERC
IL6447860013Medicare NSC