=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851528293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD PATRICK BALOG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2009
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 BOWER HILL RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15243-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-942-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 JOEL DR ORTHOPAEDIC SURGERY
-----------------------------------------------------
City | FORT CAMPBELL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42223-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-798-8323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD483804
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------