Healthcare Provider Details

I. General information

NPI: 1467582460
Provider Name (Legal Business Name): ROBERT S. BALLER, MD,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 1-2 N WILLIAMSBURG DRIVE
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

PO BOX 5247
BLOOMINGTON IL
61702-5247
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-7715
  • Fax:
Mailing address:
  • Phone: 309-662-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT S. BALLER
Title or Position: OWNER
Credential: M.D.
Phone: 309-662-7715