Healthcare Provider Details

I. General information

NPI: 1578053948
Provider Name (Legal Business Name): JEREMY ANDREW BALCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301114922
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN29310
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: