Provider Demographics
NPI:1831362375
Name:HENRY M BALBOA
Entity type:Organization
Organization Name:HENRY M BALBOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TEITEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-822-9595
Mailing Address - Street 1:100 MANETTO HILL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1311
Mailing Address - Country:US
Mailing Address - Phone:516-822-9595
Mailing Address - Fax:516-822-9592
Practice Address - Street 1:100 MANETTO HILL RD STE 103
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1311
Practice Address - Country:US
Practice Address - Phone:516-822-9595
Practice Address - Fax:516-822-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0022651213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1105370001Medicare NSC