Provider Demographics
NPI:1013535970
Name:BALK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BALK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:BALK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:38 COMMERCE AVE SW STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4252
Mailing Address - Country:US
Mailing Address - Phone:616-350-9123
Mailing Address - Fax:877-599-8202
Practice Address - Street 1:38 COMMERCE AVE SW STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4252
Practice Address - Country:US
Practice Address - Phone:616-350-9123
Practice Address - Fax:877-599-8202
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286703363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI26-2838743OtherOTHER