MEDICARE: BALI SURGICAL PRACTICE PLLC

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	2086S0129X	Vascular Surgery Physician
2	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001834802	OTHER	WV	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1689670069	OTHER	WV	INDIVIUAL NPI

General Provider Information

NPI Number	:	1659419653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALI SURGICAL PRACTICE PLLC

Provider Business Mailing Address
First Line	:	400 COURT ST STE 203
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1653
Country	:	US
Telephone Number	:	304-346-2254
Fax Number	:	304-346-3184

Provider Business Practice Location Address
First Line	:	400 COURT ST STE 203
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-1653
Country	:	US
Telephone Number	:	304-346-2254
Fax Number	:	304-346-3184

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	VEDA AMBER EVANS
Credential	:
Telephone Number	:	304-346-2254

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	09/04/2024

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Directions to “BALI SURGICAL PRACTICE PLLC ” Practice Location

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