1790930006 NPI number — MS. COLLEEN R. BALLBACH NP

Table of content: (NPI 1619426095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790930006 NPI number — MS. COLLEEN R. BALLBACH NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLBACH
Provider First Name:
COLLEEN
Provider Middle Name:
R.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790930006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CHILDREN'S SPECIALTY GROUP-CHILDREN'S WISCONSIN MILWAUK
Provider Second Line Business Mailing Address:
9000 W WISCONSIN AVE
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-266-3339
Provider Business Mailing Address Fax Number:
414-266-3735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
PEDIATRIC PALLIATIVE CARE
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-266-6469
Provider Business Practice Location Address Fax Number:
414-266-1761
Provider Enumeration Date:
12/01/2008

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: 363LP0808X , with the licence number:  3704-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 144887 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790930006 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".