Provider Demographics
NPI:1891895595
Name:BALCH, BRENDA K (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:BALCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 C GRANITE STREET
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-442-8817
Mailing Address - Fax:860-442-2011
Practice Address - Street 1:53 C GRANITE STREET
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-8817
Practice Address - Fax:860-442-2011
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031470208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NLP071OtherOXFORD
OV6152OtherHEALTH NET
001314707-00OtherBLUE CARE FAMILY PLAN
010031470CT01OtherBLUE CROSS
OV6152OtherHEALTH NET