Provider Demographics
NPI:1801024807
Name:R S BALBOA MDPC
Entity Type:Organization
Organization Name:R S BALBOA MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALDO
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALBOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-966-9556
Mailing Address - Street 1:1201 STONE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3563
Mailing Address - Country:US
Mailing Address - Phone:810-966-9556
Mailing Address - Fax:810-966-4898
Practice Address - Street 1:1201 STONE ST STE 5
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:810-966-9556
Practice Address - Fax:810-966-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB028997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110094613OtherRAILROAD MEDICARE
MI1006297Medicaid
MI0740374OtherBCBSM
MI110094613OtherRAILROAD MEDICARE