1730184789 NPI number — MICHELE K BALLOU MD

Table of content: MICHELE K BALLOU MD (NPI 1730184789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730184789 NPI number — MICHELE K BALLOU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLOU
Provider First Name:
MICHELE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRICK
Provider Other First Name:
MICHELE
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730184789
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE SULPHUR SPRINGS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24986-0457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-536-5030
Provider Business Mailing Address Fax Number:
866-903-6621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 ARH LANE
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
LOW MOOR
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24457-0007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-862-6710
Provider Business Practice Location Address Fax Number:
540-862-9167
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  0101036698 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 006099483 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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