Provider Demographics
NPI:1336245547
Name:BORGIALLI, DOMINIC A (DO)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:A
Last Name:BORGIALLI
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 1:1 HURLEY PLZ
Mailing Address - Street 2:5TH FLOOR S.O.N.
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5902
Mailing Address - Country:US
Mailing Address - Phone:810-762-7038
Mailing Address - Fax:810-760-0440
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-257-9000
Practice Address - Fax:810-760-0440
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014158207Q00000X, 207P00000X, 208D00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4542329Medicaid
MI0B51090OtherBLUE SHIELD
MIC37626080Medicare PIN
MI0B51090OtherBLUE SHIELD
MI0M54610040Medicare ID - Type Unspecified