Basic Information
| Provider Information | |||||||||
| NPI: | 1639159841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALCOM | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 SUMMER STREET | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683143 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER STREET | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
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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 | 207X00000X | 77380 | MA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2115778 | 05 | MA | MEDICAID |