Provider Demographics
NPI:1902916778
Name:BORG, BRIAN BAHMAN (MD, MHSC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:BAHMAN
Last Name:BORG
Suffix:
Gender:M
Credentials:MD, MHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 1159
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4609
Mailing Address - Country:US
Mailing Address - Phone:769-251-5674
Mailing Address - Fax:769-243-8130
Practice Address - Street 1:971 LAKELAND DR STE 1159
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:769-251-5674
Practice Address - Fax:769-243-8130
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22079207RG0100X, 207RI0008X
MDD 0059992207R00000X
MO2023026998207RG0100X, 207RI0008X
LAMD.202825207RI0008X
LA202825207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1887056Medicaid
MS02752313Medicaid
MO200128917Medicaid
LA4M2007061Medicare PIN
LA1887056Medicaid
MS302I102828Medicare PIN