Healthcare Provider Details

I. General information

NPI: 1487604906
Provider Name (Legal Business Name): ANTHONY H BALCOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 S 108TH ST
HALES CORNERS WI
53130-1321
US

IV. Provider business mailing address

5250 S 108TH ST
HALES CORNERS WI
53130-1321
US

V. Phone/Fax

Practice location:
  • Phone: 414-525-2400
  • Fax: 414-525-2401
Mailing address:
  • Phone: 414-525-2400
  • Fax: 414-525-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberV8461
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number26912
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number26912
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: