Provider Demographics
NPI:1700882776
Name:BORUCKI, ROBERT BRUCE (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRUCE
Last Name:BORUCKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 FOREST DRIVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-661-9519
Mailing Address - Fax:803-661-9819
Practice Address - Street 1:1911 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-256-1511
Practice Address - Fax:803-256-7333
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC013376207Q00000X
SC13376207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC133769Medicaid
SC7763Medicare PIN
SCC68747Medicare UPIN
SC7763Medicare ID - Type UnspecifiedGROUP NUMBER