Provider Demographics
NPI:1598257750
Name:BALSAM HEALTH OF THE CAROLINAS, PLLC
Entity Type:Organization
Organization Name:BALSAM HEALTH OF THE CAROLINAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RADWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-941-4485
Mailing Address - Street 1:PO BOX 6449
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-1525
Mailing Address - Country:US
Mailing Address - Phone:704-866-0101
Mailing Address - Fax:704-866-0103
Practice Address - Street 1:607 W GROVER ST STE 101
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-2816
Practice Address - Country:US
Practice Address - Phone:704-866-0101
Practice Address - Fax:704-866-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701414261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care