Provider Demographics
NPI:1306233242
Name:FREDERICK W. BORN
Entity type:Organization
Organization Name:FREDERICK W. BORN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:BORN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-429-2992
Mailing Address - Street 1:4077 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9513
Mailing Address - Country:US
Mailing Address - Phone:269-429-2992
Mailing Address - Fax:269-429-3372
Practice Address - Street 1:4077 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9513
Practice Address - Country:US
Practice Address - Phone:269-429-2992
Practice Address - Fax:269-429-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty