Basic Information
| Provider Information | |||||||||
| NPI: | 1578556486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALI | ||||||||
| FirstName: | SHAMMI | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR | ||||||||
| Address2: | SUITE 100 ATTN:CREDENTIALING | ||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 SW SAINT LUCIE WEST BLVD | ||||||||
| Address2: | STE 209 | ||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349861780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722048889 | ||||||||
| FaxNumber: | 7722048895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | ME 89119 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30036 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |