Provider Demographics
NPI:1760543532
Name:BALLARD, ELISABETH V (MD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:V
Last Name:BALLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5517
Mailing Address - Country:US
Mailing Address - Phone:920-336-4096
Mailing Address - Fax:920-336-8093
Practice Address - Street 1:2941 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5517
Practice Address - Country:US
Practice Address - Phone:920-336-4096
Practice Address - Fax:920-336-8093
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI412072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32583200Medicaid
WI32583200Medicaid
WI002207201Medicare PIN