Basic Information
| Provider Information | |||||||||
| NPI: | 1942291893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORK | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1254 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484461343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106644531 | ||||||||
| FaxNumber: | 8106677337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101006422 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201542 | 01 | MA | MCLAREN HEALTH PLAN | OTHER | 4133944 | 01 | MI | AETNA | OTHER | E26538 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | 0854432194 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 3303639 | 05 | MI | MEDICAID | E26538 | 01 | MI | FEDERAL HEALTH SERVICES | OTHER | 0832195 | 01 | MI | HEALTH PLUS | OTHER | C1516 | 01 | MI | MCARE | OTHER | 201542 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER |