Provider Demographics
NPI:1437671286
Name:BALLEM, GEORGIA (MD)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:BALLEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WATER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6565
Mailing Address - Country:US
Mailing Address - Phone:207-873-9841
Mailing Address - Fax:207-873-9845
Practice Address - Street 1:149 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6623
Practice Address - Country:US
Practice Address - Phone:207-453-0322
Practice Address - Fax:207-453-3093
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC171046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine