Basic Information
| Provider Information | |||||||||
| NPI: | 1225024326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORNSTEIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774693348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813419696 | ||||||||
| FaxNumber: | 2813416218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774693348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813419696 | ||||||||
| FaxNumber: | 2813416218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| 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 | 208000000X | J3747 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 88150X | 01 | BC/BS | OTHER |