Provider Demographics
NPI:1942269311
Name:BALACKO, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BALACKO
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 1:1624 PACIFIC AVE STE B
Mailing Address - Street 2:
Mailing Address - City:NATRONA HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065-2145
Mailing Address - Country:US
Mailing Address - Phone:724-226-3345
Mailing Address - Fax:724-226-2415
Practice Address - Street 1:1624 PACIFIC AVE STE B
Practice Address - Street 2:
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-2145
Practice Address - Country:US
Practice Address - Phone:724-226-3345
Practice Address - Fax:724-226-2415
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036R70E207RC0000X
PAMD036270E207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008241Medicaid
PA0014154670004Medicaid
OH2745579Medicaid
PA0014154670007Medicaid
PA0014154670007Medicaid
OH2745579Medicaid
WV3810008241Medicaid
PA0014154670004Medicaid
PA514800DXCMedicare PIN