Provider Demographics
NPI:1356311518
Name:BALLARD, MICHAEL F (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:BALLARD
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:F
Other - Last Name:BALLARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IDC
Mailing Address - Street 1:7698 KIOWA ST
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-3248
Mailing Address - Country:US
Mailing Address - Phone:901-872-7848
Mailing Address - Fax:
Practice Address - Street 1:5722 INTEGRITY DR
Practice Address - Street 2:BLDG S771
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38054-5028
Practice Address - Country:US
Practice Address - Phone:901-874-6100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman