Provider Demographics
NPI:1285649624
Name:BALLEN, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:BALLEN
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 1:1563 E DOROTHY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3897
Mailing Address - Country:US
Mailing Address - Phone:937-296-0253
Mailing Address - Fax:937-293-3183
Practice Address - Street 1:2222 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1813
Practice Address - Country:US
Practice Address - Phone:937-276-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350798342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH300137611OtherRAILROAD MEDICARE
OHCK1297OtherRAILROAD MEDICARE
OH2257007Medicaid
OH2257007Medicaid
4058053Medicare PIN
4058055Medicare PIN
OHG08709Medicare UPIN
OH4058052Medicare PIN