Provider Demographics
NPI:1679765663
Name:CONNIE BALL MD LLC
Entity Type:Organization
Organization Name:CONNIE BALL MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-748-5346
Mailing Address - Street 1:84 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066
Mailing Address - Country:US
Mailing Address - Phone:937-748-5346
Mailing Address - Fax:937-748-5369
Practice Address - Street 1:84 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066
Practice Address - Country:US
Practice Address - Phone:937-748-5346
Practice Address - Fax:937-748-5369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
363899941026OtherCARESOURCE
3996090680OtherWORKERS COMPENSATION
399609068003OtherMEDICAL MUTUAL
0112593OtherUNITED HEALTH CARE
5668002OtherAETNA
DE3333OtherRR MCR
000000338258OtherANTHEM
P00286099OtherRR MCR
D67559OtherHUMANA
OH0168894Medicaid
363899941026OtherCARESOURCE
=========OtherAETNA
363899941026OtherCARESOURCE
399609068003OtherMEDICAL MUTUAL