Provider Demographics
NPI:1659547099
Name:BALVANT K GANATRA MD PC
Entity Type:Organization
Organization Name:BALVANT K GANATRA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NOLA
Authorized Official - Middle Name:MAXINE
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-733-3570
Mailing Address - Street 1:5154 MILLER RD
Mailing Address - Street 2:SUITE A AND B
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1065
Mailing Address - Country:US
Mailing Address - Phone:810-733-3570
Mailing Address - Fax:810-733-0856
Practice Address - Street 1:5154 MILLER RD
Practice Address - Street 2:SUITE A AND B
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1065
Practice Address - Country:US
Practice Address - Phone:810-733-3570
Practice Address - Fax:810-733-0856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBG040280207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1421393Medicaid
MIA76215Medicare UPIN
MI1421393Medicaid