Healthcare Provider Details

I. General information

NPI: 1356311518
Provider Name (Legal Business Name): MICHAEL F BALLARD IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MICHAEL F BALLARD IDC

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5722 INTEGRITY DR BLDG S771
MILLINGTON TN
38054-5028
US

IV. Provider business mailing address

7698 KIOWA ST
MILLINGTON TN
38053-3248
US

V. Phone/Fax

Practice location:
  • Phone: 901-874-6100
  • Fax:
Mailing address:
  • Phone: 901-872-7848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: