Basic Information
| Provider Information | |||||||||
| NPI: | 1770575474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORST | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1760 E RIVER RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857185999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197775 | ||||||||
| FaxNumber: | 5205197910 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 E HIGHLAND AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774868 | ||||||||
| FaxNumber: | 6022309350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 04/10/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 20785 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 110354 | 05 | AZ | MEDICAID |