Provider Demographics
NPI:1336541226
Name:DR. CHARLES J. BALLAY II M.D.
Entity Type:Organization
Organization Name:DR. CHARLES J. BALLAY II M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSPEH
Authorized Official - Last Name:BALLAY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:504-934-8550
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE 707N
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-934-8550
Mailing Address - Fax:504-934-8549
Practice Address - Street 1:1111 MEDICAL CENTER BLVD,
Practice Address - Street 2:707 N
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:479-806-3626
Practice Address - Fax:504-934-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD205801207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2351753Medicaid