Provider Demographics
NPI:1992772651
Name:BALZANO, ERIC R (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:R
Last Name:BALZANO
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:PO BOX 5307
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-5307
Mailing Address - Country:US
Mailing Address - Phone:866-497-8222
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV205032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2249990Medicaid
WV1807201000Medicaid
PA1010832430002Medicaid
WV1807201000Medicaid
WV300121676OtherRAILROAD MEDICARE
OH300121463OtherRAILROAD MEDICARE
OH300121463OtherRAILROAD MEDICARE
OH2249990Medicaid
WV20503OtherHEALTH PLAN OF UPPER OH V