Provider Demographics
NPI:1821338096
Name:BALLINGER, ANDRE (LMT)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 EDENHURST ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-3004
Mailing Address - Country:US
Mailing Address - Phone:614-475-3429
Mailing Address - Fax:
Practice Address - Street 1:4488 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-5610
Practice Address - Country:US
Practice Address - Phone:614-746-6746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.019992174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12505340OtherCAQH