Basic Information
| Provider Information | |||||||||
| NPI: | 1174605810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALAVENDER | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067952601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602744092 | ||||||||
| FaxNumber: | 8602744099 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067952601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602744092 | ||||||||
| FaxNumber: | 8602744099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3638 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080003638CT12 | 01 | CT | ANTHEM BC BS | OTHER | 080003638CT13 | 01 | CT | ANTHEM BC BS | OTHER | 080003638CT15 | 01 | CT | BLUE SHIELD | OTHER | 080003638CT09 | 01 | CT | ANTHEM BLUE CROSS BLUE SH | OTHER | 080003638CT10 | 01 | CT | ANTHEM BC BS | OTHER | 004201018 | 05 | CT | MEDICAID | 080003638CT14 | 01 | CT | BLUE SHIELD | OTHER |