1104955418 NPI number — MS. RITAMARIE RISLEY BALCERZAK M.A.

Table of content: MS. RITAMARIE RISLEY BALCERZAK M.A. (NPI 1104955418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104955418 NPI number — MS. RITAMARIE RISLEY BALCERZAK M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALCERZAK
Provider First Name:
RITAMARIE
Provider Middle Name:
RISLEY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104955418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2186 3RD ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-3263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-227-8880
Provider Business Mailing Address Fax Number:
651-227-8908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2186 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-3263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-227-8880
Provider Business Practice Location Address Fax Number:
651-227-8908
Provider Enumeration Date:
03/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP1726 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 546547800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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