Healthcare Provider Details

I. General information

NPI: 1326427105
Provider Name (Legal Business Name): PAOLO NINO BALMASEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26750 PROVIDENCE PKWY STE 210
NOVI MI
48374-1212
US

IV. Provider business mailing address

26750 PROVIDENCE PKWY STE 210
NOVI MI
48374-1212
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4782
  • Fax: 248-465-4852
Mailing address:
  • Phone: 248-465-4782
  • Fax: 248-465-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301500673
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301500673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: