Provider Demographics
NPI:1053313072
Name:BALTER, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BALTER
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 1:855 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4420
Mailing Address - Country:US
Mailing Address - Phone:708-386-1000
Mailing Address - Fax:708-386-2394
Practice Address - Street 1:855 MADISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4420
Practice Address - Country:US
Practice Address - Phone:708-386-1000
Practice Address - Fax:708-386-2394
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036040403207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036040403Medicaid
ILC41850Medicare UPIN
IL390002162Medicare PIN
IL036040403Medicaid
ILC30486Medicare PIN