Provider Demographics
NPI:1649280264
Name:FERDINAND & ERESVITA BALATICO MD PC
Entity type:Organization
Organization Name:FERDINAND & ERESVITA BALATICO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERESVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALATICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-363-8823
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-0735
Mailing Address - Country:US
Mailing Address - Phone:931-363-8823
Mailing Address - Fax:931-363-1894
Practice Address - Street 1:1109 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4520
Practice Address - Country:US
Practice Address - Phone:931-363-8823
Practice Address - Fax:931-363-1894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14111207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID
TN0034Medicare ID - Type Unspecified