Healthcare Provider Details

I. General information

NPI: 1003561309
Provider Name (Legal Business Name): JEROMY LEE BALDUF PA-C, RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 MONROE ST UNIT 310
SYLVANIA OH
43560-2768
US

IV. Provider business mailing address

5700 MONROE ST UNIT 310
SYLVANIA OH
43560-2768
US

V. Phone/Fax

Practice location:
  • Phone: 419-578-7555
  • Fax: 419-539-6336
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012342
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007502RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: