MEDICARE: MR. ANDREY BALYKOV ATC ATL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL4709	FL

General Provider Information

NPI Number	:	1043913908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREY BALYKOV ATC ATL

Provider Business Mailing Address
First Line	:	8099 COLLEGE PKWY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5598
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 OASIS PALM CIR APT 405
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33991-3391
Country	:	US
Telephone Number	:	239-560-9185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	03/27/2023

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