Healthcare Provider Details

I. General information

NPI: 1477569903
Provider Name (Legal Business Name): ALEXIS ROBIN BALOMENOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58115 MAIN ST
NEW HAVEN MI
48048-2686
US

IV. Provider business mailing address

58115 MAIN ST
NEW HAVEN MI
48048-2686
US

V. Phone/Fax

Practice location:
  • Phone: 586-749-4444
  • Fax: 586-749-9114
Mailing address:
  • Phone: 586-749-4444
  • Fax: 586-749-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301066394
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: