Basic Information
| Provider Information | |||||||||
| NPI: | 1508811217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALCH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Practice Location | |||||||||
| Address1: | 2412 50TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794122504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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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 | 207R00000X | E6031 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100111106 | 01 | TX | FIRSTCARE (GRACE CLINIC OF LUBBOCK) | OTHER | 137534712 | 05 | TX | MEDICAID | 8CM983 | 01 | TX | BCBS-TX (GRACE CLINIC OF LUBBOCK) | OTHER |