Provider Demographics
NPI:1760670855
Name:BALBISSI, KAIS A (MD)
Entity Type:Individual
Prefix:
First Name:KAIS
Middle Name:A
Last Name:BALBISSI
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-979-4134
Mailing Address - Fax:423-979-4134
Practice Address - Street 1:329 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6062
Practice Address - Country:US
Practice Address - Phone:423-979-4100
Practice Address - Fax:423-979-4134
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD42438207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD0000042438OtherMEDICAL LISCENCE
TNMD0000042438OtherMEDICAL LISCENCE