Healthcare Provider Details

I. General information

NPI: 1225088651
Provider Name (Legal Business Name): MICHAEL T BALLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11531 STATE ROUTE 66
MINSTER OH
45865-9303
US

IV. Provider business mailing address

915 WEST MICHIGAN ST
SIDNEY OH
45365-2401
US

V. Phone/Fax

Practice location:
  • Phone: 937-295-2949
  • Fax: 419-628-0342
Mailing address:
  • Phone: 937-295-2949
  • Fax: 419-628-0342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-06-7026-B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: