Provider Demographics
NPI:1396739736
Name:BALAKLAW, LEE ADAM (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ADAM
Last Name:BALAKLAW
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 1:1057 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-9658
Mailing Address - Country:US
Mailing Address - Phone:606-638-4300
Mailing Address - Fax:606-638-0039
Practice Address - Street 1:1057 MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9658
Practice Address - Country:US
Practice Address - Phone:606-638-4300
Practice Address - Fax:606-638-0039
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29892207LP2900X, 207L00000X
VT042-0008748207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060588000Medicaid
3257452OtherCIGNA
KY64298920Medicaid
VT1019052Medicaid
000000050355OtherBLUE CROSS BLUE SHIELD
0287401Medicare ID - Type Unspecified
WV0060588000Medicaid