Basic Information
| Provider Information | |||||||||
| NPI: | 1932273547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALTAROWICH | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PT0002X | 4301041763 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology |
ID Information
| ID | Type | State | Issuer | Description | 010H262530 | 01 | BLUE CROSS-BLUE CROSS | OTHER | 140460510 | 05 | MI | MEDICAID | LB041763 | 01 | CHAMPUS-CHAMPUS | OTHER | LB041763 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER |