=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821338096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRE BALLINGER LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2013
-----------------------------------------------------
Last Update Date | 02/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4488 W BROAD ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43228-5610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-746-6746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3445 EDENHURST ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43224-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-475-3429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 33.019992
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------