Healthcare Provider Details

I. General information

NPI: 1063558682
Provider Name (Legal Business Name): ANI BALMANOUKIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

501 SAINT PAUL ST APT 803
BALTIMORE MD
21202-2278
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-7911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA117624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: