Provider Demographics
NPI:1487729059
Name:BALSAM, GERALD J (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:BALSAM
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 1:736 N MAGNOLIA AVE
Mailing Address - Street 2:ADVANCED PSYCHIATRIC GROUP, P.A.
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3809
Mailing Address - Country:US
Mailing Address - Phone:407-423-7149
Mailing Address - Fax:407-422-0470
Practice Address - Street 1:736 N MAGNOLIA AVE
Practice Address - Street 2:ADVANCED PSYCHIATRIC GROUP, P.A.
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3809
Practice Address - Country:US
Practice Address - Phone:407-423-7149
Practice Address - Fax:407-422-0470
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME230572084P0800X
FLME00230572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038468200Medicaid
FL93676WMedicare PIN
FL038468200Medicaid