Provider Demographics
NPI:1578045225
Name:BALOG, GWEN ELIZABETH
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ELIZABETH
Last Name:BALOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21710 BEHRING RD
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-9103
Mailing Address - Country:US
Mailing Address - Phone:989-306-7253
Mailing Address - Fax:
Practice Address - Street 1:21710 BEHRING RD
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746-9103
Practice Address - Country:US
Practice Address - Phone:989-306-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0651445599-8OtherHEALTHCARE PROVIDERS SERVICE ORGANIZATION