Provider Demographics
NPI:1285684365
Name:BALSAM, ADRIENNE M (MD)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:M
Last Name:BALSAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4711 GOLF ROAD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-933-0455
Mailing Address - Fax:847-679-8002
Practice Address - Street 1:4711 GOLF RD STE 1200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1200
Practice Address - Country:US
Practice Address - Phone:847-933-0455
Practice Address - Fax:847-679-8002
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360877772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL453950Medicare ID - Type Unspecified
ILG13897Medicare UPIN