Provider Demographics
NPI:1144325192
Name:BALANCIO, MICHELLE M (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BALANCIO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-5806
Mailing Address - Fax:248-849-5489
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-5806
Practice Address - Fax:248-849-5489
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168195367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36455230OtherCRITTENTON MEDICARE PTAN
MI3392227Medicaid
11909375OtherCAQH
MI430044430Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MI3392227Medicaid