Basic Information
| Provider Information | |||||||||
| NPI: | 1881853539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORK | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | TOBY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107065651 | ||||||||
| FaxNumber: | 4107064619 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 W LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107065651 | ||||||||
| FaxNumber: | 4107064619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2008 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 255522 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RI0200X | D77174 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 902504900 | 05 | MD | MEDICAID | S062-0553 | 01 | MD | CAREFIRST BC/BS | OTHER |