Basic Information
| Provider Information | |||||||||
| NPI: | 1093799090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANREES | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4114 S RACCOON RD | ||||||||
| Address2: | |||||||||
| City: | CANFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444069373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307938404 | ||||||||
| FaxNumber: | 3307938404 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N KEEL RIDGE RD | ||||||||
| Address2: | SENIOR HEALTHCARE ASSOCIATES -JOHN BALKO AND ASSOCIATES | ||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161483440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004718592 | ||||||||
| FaxNumber: | 8667426901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 34 002800V | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208D00000X | 34.002800 | OH | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0457590 | 05 | OH | MEDICAID |