Provider Demographics
NPI:1255357067
Name:BALBOA-MARCIACK, PABLO E (MD)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:E
Last Name:BALBOA-MARCIACK
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:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL CT
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2077
Practice Address - Country:US
Practice Address - Phone:706-602-8200
Practice Address - Fax:706-602-1354
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA135418395CMedicaid
GA135418395CMedicaid
GA135418395AMedicaid
GA52887515OtherBCBS
GA135418395BMedicaid
GA135418395CMedicaid