Provider Demographics
NPI:1265446512
Name:GARY A BALSTER MD INC
Entity Type:Organization
Organization Name:GARY A BALSTER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BALSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-299-1918
Mailing Address - Street 1:2218 S PATTERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1930
Mailing Address - Country:US
Mailing Address - Phone:937-299-1918
Mailing Address - Fax:937-299-4832
Practice Address - Street 1:2218 S PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1930
Practice Address - Country:US
Practice Address - Phone:937-299-1918
Practice Address - Fax:937-299-4832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350511532084P0800X, 2084P0804X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9319151Medicare PIN