Basic Information
| Provider Information | |||||||||
| NPI: | 1447604442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544862020 | ||||||||
| FaxNumber: | 9544868983 | ||||||||
| Practice Location | |||||||||
| Address1: | 9611 W BROWARD BLVD | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544247000 | ||||||||
| FaxNumber: | 9544246003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2016 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | UO 3505 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS14058 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 20A14294 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 018231300 | 05 | FL | MEDICAID |