Provider Demographics
NPI:1720025174
Name:BALLAST, CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:BALLAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 E STATE ROAD 44
Mailing Address - Street 2:STE A
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-4057
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:317-398-1852
Practice Address - Street 1:2158 INTELLIPLEX DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8846
Practice Address - Country:US
Practice Address - Phone:317-392-3651
Practice Address - Fax:317-398-0538
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038703A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100317710Medicaid
E48284Medicare UPIN
IN253400CMedicare PIN
742420JMedicare ID - Type Unspecified