Provider Demographics
NPI:1063481489
Name:BALASKY, KIMBERLY L (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:BALASKY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49494 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:SULLIGENT
Mailing Address - State:AL
Mailing Address - Zip Code:35586-4454
Mailing Address - Country:US
Mailing Address - Phone:205-698-7111
Mailing Address - Fax:256-698-0516
Practice Address - Street 1:49494 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:SULLIGENT
Practice Address - State:AL
Practice Address - Zip Code:35586-4454
Practice Address - Country:US
Practice Address - Phone:205-698-7111
Practice Address - Fax:205-698-0516
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO859207Q00000X
ALD.O.859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL114077Medicaid
AL1063481489Medicaid
E869OtherMDCR GROUP
AL102I081118Medicare PIN
AL114077Medicaid