Provider Demographics
NPI:1174562854
Name:BORUCH, JOHN M (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BORUCH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:101 E OLNEY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2421
Practice Address - Country:US
Practice Address - Phone:215-456-7000
Practice Address - Fax:215-254-2599
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PARN307927L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA036327Medicare ID - Type Unspecified