Provider Demographics
NPI:1487604906
Name:BALCOM, ANTHONY H (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:H
Last Name:BALCOM
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 1:5250 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1321
Mailing Address - Country:US
Mailing Address - Phone:414-525-2400
Mailing Address - Fax:414-525-2401
Practice Address - Street 1:5250 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1321
Practice Address - Country:US
Practice Address - Phone:414-525-2400
Practice Address - Fax:414-525-2401
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26912208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487604906Medicaid
007000261MOtherHUMANA
E46178Medicare UPIN
WI680860586Medicare PIN
0002P73601Medicare ID - Type Unspecified
WI1487604906Medicaid