Provider Demographics
NPI:1760564041
Name:BALTZER, RODERICK JAY (DO)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:JAY
Last Name:BALTZER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S NICOLET ST
Mailing Address - Street 2:
Mailing Address - City:MACKINAW CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49701-9657
Mailing Address - Country:US
Mailing Address - Phone:231-436-9900
Mailing Address - Fax:231-436-5727
Practice Address - Street 1:802 S MAIN ST
Practice Address - Street 2:STE 3
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721
Practice Address - Country:US
Practice Address - Phone:231-627-3002
Practice Address - Fax:231-627-3002
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1424279Medicaid
MI0805163314OtherBCBSM
MI4745626Medicaid
MI6048333Medicaid
010A660000OtherBLUE CROSS GROUP
A66000064Medicare ID - Type Unspecified