Provider Demographics
NPI:1659419653
Name:BALI SURGICAL PRACTICE PLLC
Entity type:Organization
Organization Name:BALI SURGICAL PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VEDA
Authorized Official - Middle Name:AMBER
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-346-2254
Mailing Address - Street 1:400 COURT ST STE 203
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1653
Mailing Address - Country:US
Mailing Address - Phone:304-346-2254
Mailing Address - Fax:304-346-3184
Practice Address - Street 1:400 COURT ST STE 203
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1653
Practice Address - Country:US
Practice Address - Phone:304-346-2254
Practice Address - Fax:304-346-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001834802OtherBLUE CROSS
WV3810009656Medicaid
WV1689670069OtherINDIVIUAL NPI
WV9360771Medicare PIN