Provider Demographics
NPI:1184921652
Name:NEW BALANCE OCCUPATIONAL MEDICINE, LLC
Entity type:Organization
Organization Name:NEW BALANCE OCCUPATIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ORANU
Authorized Official - Middle Name:G
Authorized Official - Last Name:IBEKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-769-4400
Mailing Address - Street 1:PO BOX 10746
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46411-0746
Mailing Address - Country:US
Mailing Address - Phone:219-769-4400
Mailing Address - Fax:219-795-1419
Practice Address - Street 1:1574 E 85TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-769-4400
Practice Address - Fax:219-795-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0401X
IN2083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201016650AMedicaid