MEDICARE: DR. THOMAS KELLY BALLARD III MD

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	207Q00000X	Family Medicine Physician	MD016530	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932300761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS KELLY BALLARD III MD

Provider Business Mailing Address
First Line	:	15 WINDWOOD DR
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-8835
Country	:	US
Telephone Number	:	731-422-3416
Fax Number	:	731-424-6120

Provider Business Practice Location Address
First Line	:	418 E BALTIMORE ST
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38301-6307
Country	:	US
Telephone Number	:	731-422-3416
Fax Number	:	731-424-6120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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