Healthcare Provider Details

I. General information

NPI: 1659569705
Provider Name (Legal Business Name): ALAN L BALKANSKY DPM SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FALLS RD SUITE 600
GRAFTON WI
53024-2612
US

IV. Provider business mailing address

101 FALLS RD SUITE 600
GRAFTON WI
53024-2612
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1940
  • Fax: 262-375-0534
Mailing address:
  • Phone: 262-375-1940
  • Fax: 262-375-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number429025
License Number StateWI

VIII. Authorized Official

Name: DR. ALAN L. BALKANSKY
Title or Position: PRESIDENT
Credential: DPM SC
Phone: 262-375-1940