Provider Demographics
NPI:1831304088
Name:BALLERT, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BALLERT
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 1:2605 KENTUCKY AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3806
Mailing Address - Country:US
Mailing Address - Phone:270-408-4368
Mailing Address - Fax:270-408-3272
Practice Address - Street 1:2605 KENTUCKY AVE STE 601
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3806
Practice Address - Country:US
Practice Address - Phone:270-408-4368
Practice Address - Fax:270-408-3272
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104223207Y00000X
KYTP352207Y00000X
KY43767207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100138780Medicaid
KYP01533444Medicare PIN
KYK126100Medicare PIN
FLBY462ZMedicare PIN
KY7100138780Medicaid
KYP400023822Medicare PIN