Provider Demographics
NPI:1861652463
Name:BALAM, TUCKER G (DO)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:G
Last Name:BALAM
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:714 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1035
Practice Address - Country:US
Practice Address - Phone:574-647-7477
Practice Address - Fax:574-647-3655
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003535A207Q00000X, 207Q00000X
IN11014493A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201382680Medicaid
WA0297867OtherL&I
WA314774OtherL&I POST 7/21/13
WA1861652463Medicaid
IN162520049Medicare PIN
WAG8920246, G8920247Medicare PIN
WA0297867OtherL&I
IN201382680Medicaid