Provider Demographics
NPI:1982726766
Name:PETER E. BALSAM, MD, FACG
Entity Type:Organization
Organization Name:PETER E. BALSAM, MD, FACG
Other - Org Name:NA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALSAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-264-3330
Mailing Address - Street 1:4987 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7307
Mailing Address - Country:US
Mailing Address - Phone:321-264-3330
Mailing Address - Fax:321-268-2286
Practice Address - Street 1:4987 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7307
Practice Address - Country:US
Practice Address - Phone:321-264-3330
Practice Address - Fax:321-268-2286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46070207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46070OtherMED LICENSE NUMBER
FLD51350Medicare UPIN
FL46070OtherMED LICENSE NUMBER