Provider Demographics
NPI:1932586278
Name:BORTA, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BORTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27750 W HIGHWAY 22
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010
Mailing Address - Country:US
Mailing Address - Phone:847-381-6051
Mailing Address - Fax:847-381-6084
Practice Address - Street 1:27750 W HIGHWAY 22
Practice Address - Street 2:SUITE 130
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2379
Practice Address - Country:US
Practice Address - Phone:847-381-6051
Practice Address - Fax:847-381-6084
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000446246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant