Provider Demographics
NPI:1629554225
Name:BALLOUT INTERNATIONAL LLC
Entity type:Organization
Organization Name:BALLOUT INTERNATIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUSSIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-574-2965
Mailing Address - Street 1:1931 19TH PL
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3555
Mailing Address - Country:US
Mailing Address - Phone:313-574-2965
Mailing Address - Fax:702-441-2580
Practice Address - Street 1:1931 19TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3555
Practice Address - Country:US
Practice Address - Phone:313-574-2965
Practice Address - Fax:702-441-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJL435AOtherMEDICARE PTAN
FL100849400Medicaid
FLDY5252OtherRRMEDICARE PTAN