Basic Information
Provider Information | |||||||||
NPI: | 1730421819 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALENCIC | ||||||||
FirstName: | JORDAN | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 N 32ND ST | ||||||||
Address2: | MAIL CODE H039 | ||||||||
City: | CAMP HILL | ||||||||
State: | PA | ||||||||
PostalCode: | 170112918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177309782 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 UNIVERSITY DR | ||||||||
Address2: | MAIL CODE H039 | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170332360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175318903 | ||||||||
FaxNumber: | 7175315831 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2013 | ||||||||
LastUpdateDate: | 12/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS018254 | PA | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.