Provider Demographics
NPI:1235991787
Name:AETERNUM FORTIS MEDICAL PLLC
Entity Type:Organization
Organization Name:AETERNUM FORTIS MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:210-364-3569
Mailing Address - Street 1:7180 BANDERA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1295
Mailing Address - Country:US
Mailing Address - Phone:210-521-6886
Mailing Address - Fax:210-521-6608
Practice Address - Street 1:7180 BANDERA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1295
Practice Address - Country:US
Practice Address - Phone:210-521-6886
Practice Address - Fax:210-521-6608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty