Provider Demographics
NPI:1083637730
Name:BALL, BENJAMIN EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:BALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 W MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-9015
Mailing Address - Country:US
Mailing Address - Phone:419-483-7240
Mailing Address - Fax:419-483-2543
Practice Address - Street 1:1255 W MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9015
Practice Address - Country:US
Practice Address - Phone:419-483-7240
Practice Address - Fax:419-483-2543
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0804044Medicaid
OHBA0676502Medicare ID - Type Unspecified
OH0804044Medicaid