Healthcare Provider Details

I. General information

NPI: 1174519847
Provider Name (Legal Business Name): FARYAL BALOCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 ACCESS RD SUITE C
COVINGTON GA
30014-1987
US

IV. Provider business mailing address

1775 ACCESS RD SUITE C
COVINGTON GA
30014-1987
US

V. Phone/Fax

Practice location:
  • Phone: 678-729-0003
  • Fax: 770-255-0125
Mailing address:
  • Phone: 678-729-0003
  • Fax: 770-255-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number050939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: