Basic Information
| Provider Information | |||||||||
| NPI: | 1801024807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | R S BALBOA MDPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 STONE ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109669556 | ||||||||
| FaxNumber: | 8109664898 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 STONE ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109669556 | ||||||||
| FaxNumber: | 8109664898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | BALBOA | ||||||||
| AuthorizedOfficialFirstName: | RONALDO | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8109669556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | RB028997 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110094613 | 01 | MI | RAILROAD MEDICARE | OTHER | 1006297 | 05 | MI | MEDICAID | 0740374 | 01 | MI | BCBSM | OTHER |