Provider Demographics
NPI:1821090549
Name:BALLARD, ROBERT CHEATHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHEATHAM
Last Name:BALLARD
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 1:151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2670
Mailing Address - Country:US
Mailing Address - Phone:901-853-4747
Mailing Address - Fax:901-853-6716
Practice Address - Street 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2670
Practice Address - Country:US
Practice Address - Phone:901-853-4747
Practice Address - Fax:901-853-6716
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN007768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03724Medicare UPIN
TN3373912Medicare ID - Type UnspecifiedMEDICARE ID