Basic Information
| Provider Information | |||||||||
| NPI: | 1205110368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALCOLM | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | IDMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4099 FORREST RUN CIR | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316056538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748557051 | ||||||||
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| Practice Location | |||||||||
| Address1: | 57950 LEAVENWORTH ST | ||||||||
| Address2: | |||||||||
| City: | MCCONNELL AFB | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672213505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167596300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2011 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1003X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians |
No ID Information.