Provider Demographics
NPI:1922104660
Name:BALOG BREMEN VISION CENTER P C
Entity Type:Organization
Organization Name:BALOG BREMEN VISION CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-546-3820
Mailing Address - Street 1:1425 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1951
Mailing Address - Country:US
Mailing Address - Phone:574-546-3820
Mailing Address - Fax:574-546-3810
Practice Address - Street 1:1425 W PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1951
Practice Address - Country:US
Practice Address - Phone:574-546-3820
Practice Address - Fax:574-546-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001983A152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDA1502OtherRAILROAD MEDICARE
INDA1502OtherRAILROAD MEDICARE
IN203070Medicare PIN