Provider Demographics
NPI:1659419653
Name:BALI SURGICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:BALI SURGICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-767-7800
Mailing Address - Street 1:401 DIVISION ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1455
Mailing Address - Country:US
Mailing Address - Phone:304-767-7800
Mailing Address - Fax:304-767-7805
Practice Address - Street 1:401 DIVISION ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1455
Practice Address - Country:US
Practice Address - Phone:304-767-7800
Practice Address - Fax:304-767-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21044208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1689670069OtherINDIVIUAL NPI
WV3810009656Medicaid
WVH75991Medicare UPIN
WV9360771Medicare PIN