Provider Demographics
NPI:1114123163
Name:BALCH, GLEN C (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:C
Last Name:BALCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-5870
Mailing Address - Fax:214-648-1118
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:UNIVERSITY OF TEXAS SOUTHWESTERN UNIVERSITY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-8548
Practice Address - Country:US
Practice Address - Phone:214-648-5870
Practice Address - Fax:214-648-1118
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXN42762086X0206X
IL036-118605208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-118605OtherIL STATE LIC
TXN4276OtherTX STATE MEDICAL LIC