Healthcare Provider Details

I. General information

NPI: 1407174576
Provider Name (Legal Business Name): NATHAN SHANE BALUSIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WATERVILLE MONCLOVA RD SUITE A
WATERVILLE OH
43566-1099
US

IV. Provider business mailing address

900 WATERVILLE MONCLOVA RD SUITE A
WATERVILLE OH
43566-1099
US

V. Phone/Fax

Practice location:
  • Phone: 419-878-3010
  • Fax: 419-878-3236
Mailing address:
  • Phone: 419-878-3010
  • Fax: 419-878-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.120628
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: