Provider Demographics
NPI:1760461073
Name:BALWALLY, ATUL N (MD)
Entity Type:Individual
Prefix:
First Name:ATUL
Middle Name:N
Last Name:BALWALLY
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 1:1222 S PATTERSON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2684
Mailing Address - Country:US
Mailing Address - Phone:937-496-2600
Mailing Address - Fax:937-496-2610
Practice Address - Street 1:1222 S PATTERSON BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2684
Practice Address - Country:US
Practice Address - Phone:937-496-2600
Practice Address - Fax:937-496-2610
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070075207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000362OtherMEDICARE COMPLETE
040016607OtherMEDICARE RAILROAD
1000362OtherUNITED HEALTH CARE
0254148OtherOHIO DEPT OF HEALTH & HUM
2597293OtherAETNA
000000209357OtherANTHEM
0254148OtherBCMH
0254148OtherOHIO DEPT OF HEALTH & HUM
OHBA0804432Medicare PIN