Provider Demographics
NPI:1962517870
Name:BORODITSKY, SHANE ALEX (DC)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ALEX
Last Name:BORODITSKY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 582774
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55458-2774
Mailing Address - Country:US
Mailing Address - Phone:612-281-3575
Mailing Address - Fax:612-605-8257
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:SUITE L70
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:612-281-3575
Practice Address - Fax:612-605-8257
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3976111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110238OtherHEALTH PARTNERS
MN329G7BOOtherBLUE CROSS / BLUE SHIELD
MN44-50913OtherMEDICA
U89581Medicare UPIN