Provider Demographics
NPI:1700882776
Name:BORUCKI, ROBERT B (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:BORUCKI
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:PO BOX 2246
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-2246
Mailing Address - Country:US
Mailing Address - Phone:803-256-1511
Mailing Address - Fax:803-256-7333
Practice Address - Street 1:1911 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-256-1511
Practice Address - Fax:803-256-7333
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC013376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC133769Medicaid
SC7763Medicare PIN
SCC68747Medicare UPIN
SC7763Medicare ID - Type UnspecifiedGROUP NUMBER