Provider Demographics
NPI:1629149984
Name:BALLARD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BALLARD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-244-9750
Mailing Address - Street 1:1115 WHISKEYTOWN CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0227
Mailing Address - Country:US
Mailing Address - Phone:530-244-9750
Mailing Address - Fax:530-244-0960
Practice Address - Street 1:1115 WHISKEYTOWN CT
Practice Address - Street 2:SUITE B
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0227
Practice Address - Country:US
Practice Address - Phone:530-244-9750
Practice Address - Fax:530-244-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG017510207Q00000X
CAG14717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ89207ZOtherBLUE SHIELD PROVIDER #
CAGR0001720Medicaid
CAZZZ89207ZOtherBLUE SHIELD PROVIDER #
CA=========OtherBLUE CROSS PROVIDER #
CAGR0001720Medicaid
CAA39317Medicare UPIN
CAC01193Medicare ID - Type UnspecifiedRAILROAD MCARE GROUP #