Provider Demographics
NPI:1740290600
Name:BALUGA, ANTONIO R (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:R
Last Name:BALUGA
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 6107
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125
Mailing Address - Country:US
Mailing Address - Phone:815-397-4142
Mailing Address - Fax:815-397-4144
Practice Address - Street 1:6905 E STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-397-4142
Practice Address - Fax:815-397-4144
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00149184OtherMEDICARE RAILROAD
ILP00149184OtherMEDICARE RAILROAD
ILL90337Medicare ID - Type Unspecified
IL5378720001Medicare NSC