Healthcare Provider Details

I. General information

NPI: 1073741625
Provider Name (Legal Business Name): PAUL R BALASH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 413
OAK LAWN IL
60453-2662
US

IV. Provider business mailing address

4400 W 95TH ST STE 413
OAK LAWN IL
60453-2662
US

V. Phone/Fax

Practice location:
  • Phone: 708-346-4055
  • Fax: 708-499-0948
Mailing address:
  • Phone: 708-346-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036129228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: