Provider Demographics
NPI:1467420786
Name:BALL, GREGORY MARK (MSPT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:BALL
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 EAST MAIN ST
Mailing Address - Street 2:STE 600
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624
Mailing Address - Country:US
Mailing Address - Phone:830-990-2699
Mailing Address - Fax:830-990-9088
Practice Address - Street 1:1425 EAST MAIN ST
Practice Address - Street 2:STE 600
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624
Practice Address - Country:US
Practice Address - Phone:830-990-2699
Practice Address - Fax:830-990-9088
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1142528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8T4688OtherBLUE CROSS
8T4688OtherBLUE CROSS