1710957626 NPI number — PHILLIP E BALMENTI DPM

Table of content: PHILLIP E BALMENTI DPM (NPI 1710957626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710957626 NPI number — PHILLIP E BALMENTI DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALMENTI
Provider First Name:
PHILLIP
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1710957626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
827 MCKAY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-5790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-758-1422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 MCKAY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-5790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-758-1422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2006

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: 213E00000X , with the licence number:  36001644 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0240895 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 341223965026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000116349 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34122396500 . This is a "WORKMANS COPM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341229365001 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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