Provider Demographics
NPI:1184801441
Name:BALLISTY, MARIANNE MULLIN (MD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:MULLIN
Last Name:BALLISTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:MULLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1987
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1987
Mailing Address - Country:US
Mailing Address - Phone:828-253-3322
Mailing Address - Fax:828-253-1895
Practice Address - Street 1:534 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4612
Practice Address - Country:US
Practice Address - Phone:828-213-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-011272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920731Medicaid
NCP01090765OtherRR MEDICARE
NC5920731Medicaid
NCNC8200BMedicare PIN