Provider Demographics
NPI:1972781250
Name:MICHAEL C BALOGA DPM, PC
Entity Type:Organization
Organization Name:MICHAEL C BALOGA DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALOGA, DPM,PC
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, PC
Authorized Official - Phone:570-654-4371
Mailing Address - Street 1:810 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18643-2768
Mailing Address - Country:US
Mailing Address - Phone:570-654-4371
Mailing Address - Fax:570-654-0455
Practice Address - Street 1:810 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:WEST PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18643-2768
Practice Address - Country:US
Practice Address - Phone:570-654-4371
Practice Address - Fax:570-654-0455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003071L213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028012370001Medicaid