Provider Demographics
NPI:1669552352
Name:BALK-KRADEL, SUSAN LYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNNE
Last Name:BALK-KRADEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2042
Mailing Address - Country:US
Mailing Address - Phone:850-913-8313
Mailing Address - Fax:850-913-8314
Practice Address - Street 1:1000 W 11TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2042
Practice Address - Country:US
Practice Address - Phone:850-913-8313
Practice Address - Fax:850-913-8314
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00661762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
104029OtherVALUEOPTIONS
FL32498OtherBCBS-FL
1072896OtherCAQH
E86005Medicare UPIN
FL32498OtherBCBS-FL