Provider Demographics
NPI:1770578304
Name:BALABANOV, ANTOANETA Y (MD)
Entity type:Individual
Prefix:DR
First Name:ANTOANETA
Middle Name:Y
Last Name:BALABANOV
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:SUITE 348 MURDOCK
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-6203
Mailing Address - Fax:312-942-2238
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 1106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5936
Practice Address - Fax:312-942-2380
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0361032422084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103242Medicaid
BB7272432OtherUS DEPT OF JUSTICE
IL336064985OtherIL DEPT OF PROF REG
ILL86190Medicare ID - Type Unspecified
IL036103242Medicaid