Basic Information
| Provider Information | |||||||||
| NPI: | 1255357067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALBOA-MARCIACK | ||||||||
| FirstName: | PABLO | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12938 | ||||||||
| Address2: | C/O CLINIC MANAGEMENT | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066027800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL CT | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307012077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066028200 | ||||||||
| FaxNumber: | 7066021354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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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 | 207Q00000X | 055409 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 135418395C | 05 | GA | MEDICAID |