MEDICARE: GARY A BALSTER MD INC

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	2084P0804X	Child & Adolescent Psychiatry Physician	35051153	OH
2	2084P0805X	Geriatric Psychiatry Physician	35051153	OH
3	2084P0800X	Psychiatry Physician	35051153	OH

General Provider Information

NPI Number	:	1265446512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY A BALSTER MD INC

Provider Business Mailing Address
First Line	:	2218 S PATTERSON BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45409-1930
Country	:	US
Telephone Number	:	937-299-1918
Fax Number	:	937-299-4832

Provider Business Practice Location Address
First Line	:	2218 S PATTERSON BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45409-1930
Country	:	US
Telephone Number	:	937-299-1918
Fax Number	:	937-299-4832

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY ALLEN BALSTER
Credential	:	M.D.
Telephone Number	:	937-299-1918

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	05/19/2011

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