Healthcare Provider Details

I. General information

NPI: 1659419653
Provider Name (Legal Business Name): BALI SURGICAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COURT ST STE 203
CHARLESTON WV
25301-1653
US

IV. Provider business mailing address

400 COURT ST STE 203
CHARLESTON WV
25301-1653
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-2254
  • Fax: 304-346-3184
Mailing address:
  • Phone: 304-346-2254
  • Fax: 304-346-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: VEDA AMBER EVANS
Title or Position: BILLING MANAGER
Credential:
Phone: 304-346-2254