MEDICARE: EDWARD LEE BALABAN MD

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	2084P0800X	Psychiatry Physician	159928	NY
2	2084P0800X	Psychiatry Physician	028942	CT

General Provider Information

NPI Number	:	1891802666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD LEE BALABAN MD

Provider Business Mailing Address
First Line	:	1175 DICKINSON ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01108-3143
Country	:	US
Telephone Number	:	413-244-8033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1175 DICKINSON ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01108-3143
Country	:	US
Telephone Number	:	413-244-8033
Fax Number	:

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

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	06/10/2014

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