Provider Demographics
NPI:1225317365
Name:BALLARD, KEVIN M (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BALLARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3157
Mailing Address - Country:US
Mailing Address - Phone:855-871-1526
Mailing Address - Fax:
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-952-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112208AMedicaid
GA003112208BMedicaid
GA003112208BMedicaid