Provider Demographics
NPI:1730520172
Name:J M BALDUS, INC
Entity type:Organization
Organization Name:J M BALDUS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BALDUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:763-913-6292
Mailing Address - Street 1:3032 HIGHVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9422
Mailing Address - Country:US
Mailing Address - Phone:763-913-6292
Mailing Address - Fax:
Practice Address - Street 1:5200 MAYWOOD RD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1775
Practice Address - Country:US
Practice Address - Phone:763-913-6292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0796261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6500552000Medicaid
MN680002120Medicare UPIN