Provider Demographics
NPI:1114022183
Name:BALAGNA, TERRY (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:BALAGNA
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:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62525-0587
Mailing Address - Country:US
Mailing Address - Phone:800-815-3365
Mailing Address - Fax:631-321-4235
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073894-2Medicaid
IL273601OtherHEALTH LINK
IL05823820OtherBCBS
IL615740Medicare PIN
ILL83256Medicare PIN
ILE24649Medicare UPIN