Healthcare Provider Details

I. General information

NPI: 1164621959
Provider Name (Legal Business Name): BRIDGETTE GALYE BALASKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S EXTENSION RD
MESA AZ
85210-1292
US

IV. Provider business mailing address

3540 E BASELINE RD STE 150
PHOENIX AZ
85042-9630
US

V. Phone/Fax

Practice location:
  • Phone: 480-615-3800
  • Fax: 480-615-3861
Mailing address:
  • Phone: 602-808-2700
  • Fax: 602-808-2799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number45963
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: