Provider Demographics
NPI:1477548840
Name:BALASKAS, THOMAS NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:NICHOLAS
Last Name:BALASKAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E PARIS AVE SE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-285-3310
Mailing Address - Fax:616-285-3266
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-285-3310
Practice Address - Fax:616-285-3266
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062864174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC43246Medicare UPIN
MI0M67330Medicare ID - Type Unspecified