Provider Demographics
NPI:1629554225
Name:BALLOUT INTERNATIONAL LLC
Entity Type:Organization
Organization Name:BALLOUT INTERNATIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUSSIEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-574-2965
Mailing Address - Street 1:5200 BABCOCK ST NE STE 303
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4648
Mailing Address - Country:US
Mailing Address - Phone:321-987-6881
Mailing Address - Fax:321-603-3560
Practice Address - Street 1:5200 BABCOCK STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4648
Practice Address - Country:US
Practice Address - Phone:313-574-2965
Practice Address - Fax:321-603-3560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100849400Medicaid
FLDY5252OtherRRMEDICARE PTAN
FLJL435AOtherMEDICARE PTAN