MEDICARE: DR. SUSAN WANDA BALKE DO

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	207Q00000X	Family Medicine Physician	N6963	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124013925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN WANDA BALKE DO

Provider Business Mailing Address
First Line	:	171 CHERRY ST
Second Line	:
City	:	MARIANNA
State	:	AR
Zip	:	72360-1938
Country	:	US
Telephone Number	:	870-295-6205
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 CHERRY ST
Second Line	:
City	:	MARIANNA
State	:	AR
Zip	:	72360-1938
Country	:	US
Telephone Number	:	870-295-6205
Fax Number	:

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

Provider Enumeration Date	:	09/18/2005
Last Update Date	:	09/07/2007

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