Provider Demographics
NPI:1437287232
Name:ROBERT BALESTRERO, MD, PC
Entity Type:Organization
Organization Name:ROBERT BALESTRERO, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BALESTRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-348-0859
Mailing Address - Street 1:1100 E MIGHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-1312
Mailing Address - Country:US
Mailing Address - Phone:989-348-0859
Mailing Address - Fax:
Practice Address - Street 1:1100 E MIGHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1312
Practice Address - Country:US
Practice Address - Phone:989-348-0859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicaid
MIPENDINGMedicaid