Provider Demographics
NPI:1891802666
Name:BALABAN, EDWARD LEE (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:BALABAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 DICKINSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-3143
Mailing Address - Country:US
Mailing Address - Phone:413-244-8033
Mailing Address - Fax:
Practice Address - Street 1:1175 DICKINSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-3143
Practice Address - Country:US
Practice Address - Phone:413-244-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1599282084P0800X
CT0289422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E17077Medicare UPIN
NYRA9437Medicare ID - Type UnspecifiedMEDICARE B - UPSTATE NY