Provider Demographics
NPI:1225088651
Name:BALLAS, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:BALLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 WEST MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2401
Mailing Address - Country:US
Mailing Address - Phone:937-295-2949
Mailing Address - Fax:419-628-0342
Practice Address - Street 1:11531 STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-9303
Practice Address - Country:US
Practice Address - Phone:937-295-2949
Practice Address - Fax:419-628-0342
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-7026-B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101106Medicaid
OH0101106Medicaid
OHF90920Medicare UPIN