Healthcare Provider Details

I. General information

NPI: 1174762108
Provider Name (Legal Business Name): LESLI A. BALLARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2009
Last Update Date: 02/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3199 BLUETT RD
ANN ARBOR MI
48105-1427
US

IV. Provider business mailing address

3199 BLUETT RD
ANN ARBOR MI
48105-1427
US

V. Phone/Fax

Practice location:
  • Phone: 734-623-2749
  • Fax:
Mailing address:
  • Phone: 734-623-2749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301066370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: