Healthcare Provider Details

I. General information

NPI: 1013017094
Provider Name (Legal Business Name): MATTHEW T. BALLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N HUMPHREYS BLVD
MEMPHIS TN
38120-2146
US

IV. Provider business mailing address

100 N HUMPHREYS BLVD
MEMPHIS TN
38120-2146
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-0055
  • Fax: 901-685-2969
Mailing address:
  • Phone: 901-683-0055
  • Fax: 901-685-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberL0014
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number50791
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35071913B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: