Basic Information
| Provider Information | |||||||||
| NPI: | 1386824167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALIC | ||||||||
| FirstName: | IVANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4036 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430161303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145699496 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7625 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430169649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147171800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N1990 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 35.124474 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID | 282771901 | 05 | TX | MEDICAID | 0112766 | 05 | OH | MEDICAID |