Provider Demographics
NPI:1013353879
Name:ELLIOTT, BALAAM T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BALAAM
Middle Name:T
Last Name:ELLIOTT
Suffix:JR
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:PO BOX 669935
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0116
Mailing Address - Country:US
Mailing Address - Phone:770-876-3345
Mailing Address - Fax:
Practice Address - Street 1:4117 WALTON WAY
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3494
Practice Address - Country:US
Practice Address - Phone:770-876-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA13613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics