Provider Demographics
NPI:1932300761
Name:BALLARD, THOMAS KELLY III (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:KELLY
Last Name:BALLARD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15 WINDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8835
Mailing Address - Country:US
Mailing Address - Phone:731-422-3416
Mailing Address - Fax:731-424-6120
Practice Address - Street 1:418 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6307
Practice Address - Country:US
Practice Address - Phone:731-422-3416
Practice Address - Fax:731-424-6120
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD016530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3017841Medicaid
TND71832Medicare UPIN
TN3017841Medicare ID - Type Unspecified