Healthcare Provider Details

I. General information

NPI: 1053286815
Provider Name (Legal Business Name): EVOLUTIONARY HEALTHCARE WEST VIRGINIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3006 MOUNT VERNON RD STE 1075
HURRICANE WV
25526-0318
US

IV. Provider business mailing address

1931 19TH PL
VERO BEACH FL
32960-3555
US

V. Phone/Fax

Practice location:
  • Phone: 321-387-9451
  • Fax:
Mailing address:
  • Phone: 321-387-9451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: HUSSIEN A BALLOUT
Title or Position: OWNER
Credential: MD
Phone: 321-387-9451