Provider Demographics
NPI:1609884220
Name:BALOK, EDWARD MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MICHAEL
Last Name:BALOK
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 1:4050 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2908
Mailing Address - Country:US
Mailing Address - Phone:810-329-9045
Mailing Address - Fax:810-329-8732
Practice Address - Street 1:4050 RIVER RD
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2908
Practice Address - Country:US
Practice Address - Phone:810-329-9045
Practice Address - Fax:810-329-8732
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEB055964207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180G410170OtherBCBS GROUP
MI103283901Medicaid
MI0741045OtherBCBS IINDIVIDUAL
MI0M78860001Medicare PIN
MI0741045OtherBCBS IINDIVIDUAL
F86821Medicare UPIN