=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003814559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS BALITSKI OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 06/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 LOCUST AVE STE 2
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15301-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-228-1028
-----------------------------------------------------
Fax | 888-506-6237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 LOCUST AVE STE 2
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15301-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-228-1028
-----------------------------------------------------
Fax | 888-506-6237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | OEG000676
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG000676
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------