Provider Demographics
NPI:1932103405
Name:BALKO, GREGORY RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RUSSELL
Last Name:BALKO
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 1:401 CASTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1159
Mailing Address - Country:US
Mailing Address - Phone:970-544-1228
Mailing Address - Fax:
Practice Address - Street 1:401 CASTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1159
Practice Address - Country:US
Practice Address - Phone:970-544-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-11
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37036207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92854532Medicaid
CO92854532Medicaid
COG47922Medicare UPIN