MEDICARE: EVOLUTIONARY HEALTHCARE WEST VIRGINIA PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	204D00000X	Neuromusculoskeletal Medicine & OMM Physician

General Provider Information

NPI Number	:	1053286815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLUTIONARY HEALTHCARE WEST VIRGINIA PLLC

Provider Business Mailing Address
First Line	:	1931 19TH PL
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3555
Country	:	US
Telephone Number	:	321-387-9451
Fax Number	:

Provider Business Practice Location Address
First Line	:	3006 MOUNT VERNON RD STE 1075
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-0318
Country	:	US
Telephone Number	:	321-387-9451
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HUSSIEN BALLOUT
Credential	:	MD
Telephone Number	:	321-387-9451

Provider Enumeration Date	:	10/09/2025
Last Update Date	:	04/17/2026

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