Basic Information
| Provider Information | |||||||||
| NPI: | 1457315038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTEN MEDICAL STAFF SERVICES | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577016000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057197109 | ||||||||
| FaxNumber: | 6057191027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056444004 | ||||||||
| FaxNumber: | 6056444006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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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 | 37593 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1971 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 791313300 | 05 | MN | MEDICAID |