Provider Demographics
NPI:1144817727
Name:BALOG, MARY A
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
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 1:6590 FAIRWEATHER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-2853
Mailing Address - Country:US
Mailing Address - Phone:216-671-4161
Mailing Address - Fax:
Practice Address - Street 1:6590 FAIRWEATHER DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-2853
Practice Address - Country:US
Practice Address - Phone:216-671-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant