Provider Demographics
NPI:1932711108
Name:BALSAM, TYLER
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:BALSAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6906 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-4248
Mailing Address - Country:US
Mailing Address - Phone:412-269-2501
Mailing Address - Fax:
Practice Address - Street 1:6906 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108-4248
Practice Address - Country:US
Practice Address - Phone:412-269-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP454838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist