Basic Information
| Provider Information | |||||||||
| NPI: | 1013090216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALKO | ||||||||
| FirstName: | JILLANN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 711841 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432710001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043469400 | ||||||||
| FaxNumber: | 3047208461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 J D ANDERSON DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265053494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984000 | ||||||||
| FaxNumber: | 3042936963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 50514 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 001706470 | 01 | WV | MSBSBS | OTHER | DA0096 | 01 | WV | RR MEDICARE | OTHER | 27005299701 | 01 | WV | WORKERS COMP | OTHER | 270052997004 | 01 | WV | TRICARE | OTHER | 0207026000 | 05 | WV | MEDICAID | 27005299701 | 01 | WV | BRICKSTREET | OTHER | P00207323 | 01 | WV | RR MEDICARE | OTHER | 001720735 | 01 | WV | MT STATE BCBS | OTHER | 2601027000 | 05 | WV | MEDICAID |