Provider Demographics
NPI:1265656342
Name:RICHARD ALLAN BALTER, MD FACP
Entity Type:Organization
Organization Name:RICHARD ALLAN BALTER, MD FACP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-331-1000
Mailing Address - Street 1:6 STONE GATE CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1346
Mailing Address - Country:US
Mailing Address - Phone:631-331-1000
Mailing Address - Fax:631-928-7436
Practice Address - Street 1:6 STONE GATE CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1346
Practice Address - Country:US
Practice Address - Phone:631-331-1000
Practice Address - Fax:631-928-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1397591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00699683Medicaid
B78913Medicare UPIN
NY00699683Medicaid