1457576621 NPI number — MS. PAMELA A BALLARD DC

Table of content: MS. PAMELA A BALLARD DC (NPI 1457576621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457576621 NPI number — MS. PAMELA A BALLARD DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLARD
Provider First Name:
PAMELA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457576621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINAH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60157-0460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-529-0077
Provider Business Mailing Address Fax Number:
630-529-0087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7N315 SYCAMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINAH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60157-9799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-307-7463
Provider Business Practice Location Address Fax Number:
630-529-0087
Provider Enumeration Date:
04/14/2007

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: 111NR0400X , with the licence number:  038-006728 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02232227 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 208982 . This is a "MEDICARE GROUP NO." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 038006728 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com