Healthcare Provider Details

I. General information

NPI: 1477548840
Provider Name (Legal Business Name): THOMAS NICHOLAS BALASKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE SUITE 210
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

1000 E PARIS AVE SE SUITE 210
GRAND RAPIDS MI
49546-3680
US

V. Phone/Fax

Practice location:
  • Phone: 616-285-3310
  • Fax: 616-285-3266
Mailing address:
  • Phone: 616-285-3310
  • Fax: 616-285-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301062864
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: