Provider Demographics
NPI:1255394227
Name:BORG, BRYSON DALE (MD)
Entity type:Individual
Prefix:
First Name:BRYSON
Middle Name:DALE
Last Name:BORG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:STE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5700
Mailing Address - Fax:216-255-5701
Practice Address - Street 1:4357 THE MASTERS DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-9514
Practice Address - Country:US
Practice Address - Phone:855-292-1401
Practice Address - Fax:866-396-8340
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350827262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7617030Medicaid
ID808272700Medicaid
SCQ11300Medicaid
OH2601152Medicaid
CACZ308XMedicare PIN
MS512I300163Medicare PIN
SCQ11300Medicaid
ID808272700Medicaid
CACZ308SMedicare PIN