Provider Demographics
NPI:1336134782
Name:BALL, RUSSELL A (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:BALL
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 1:2006 NEW GARDEN RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2566
Mailing Address - Country:US
Mailing Address - Phone:336-609-6240
Mailing Address - Fax:336-609-6238
Practice Address - Street 1:2006 NEW GARDEN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2566
Practice Address - Country:US
Practice Address - Phone:336-609-6240
Practice Address - Fax:336-609-6238
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901503174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC220029646OtherRAILROAD MEDICARE
G95972Medicare UPIN