Provider Demographics
NPI:1639401953
Name:BALKCUM, MICHAEL WARREN (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WARREN
Last Name:BALKCUM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6298 VETERANS PKWY
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6258
Mailing Address - Country:US
Mailing Address - Phone:706-324-3558
Mailing Address - Fax:706-320-5484
Practice Address - Street 1:6298 VETERANS PKWY
Practice Address - Street 2:SUITE 5A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-6258
Practice Address - Country:US
Practice Address - Phone:706-324-3558
Practice Address - Fax:706-320-5484
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBPTMedicare PIN