Basic Information
| Provider Information | |||||||||
| NPI: | 1760564041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALTZER | ||||||||
| FirstName: | RODERICK | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 S NICOLET ST | ||||||||
| Address2: | |||||||||
| City: | MACKINAW CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497019657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314369900 | ||||||||
| FaxNumber: | 2314365727 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 S MAIN ST | ||||||||
| Address2: | STE 3 | ||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316273002 | ||||||||
| FaxNumber: | 2316273002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101006586 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1424279 | 05 | MI | MEDICAID | 0805163314 | 01 | MI | BCBSM | OTHER | 4745626 | 05 | MI | MEDICAID | 6048333 | 05 | MI | MEDICAID | 010A660000 | 01 | BLUE CROSS GROUP | OTHER |