Healthcare Provider Details

I. General information

NPI: 1972781250
Provider Name (Legal Business Name): MICHAEL C BALOGA DPM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WYOMING AVE
WEST PITTSTON PA
18643-2768
US

IV. Provider business mailing address

810 WYOMING AVE
WEST PITTSTON PA
18643-2768
US

V. Phone/Fax

Practice location:
  • Phone: 570-654-4371
  • Fax: 570-654-0455
Mailing address:
  • Phone: 570-654-4371
  • Fax: 570-654-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC003071L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC003071L
License Number StatePA

VIII. Authorized Official

Name: MICHAEL C BALOGA, DPM,PC
Title or Position: OWNER DR
Credential: DPM, PC
Phone: 570-654-4371