Provider Demographics
NPI:1841497526
Name:BALLECER, MICHELLE MARIE (MD, MPH)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:BALLECER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20325 N 51ST AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5674
Mailing Address - Country:US
Mailing Address - Phone:623-249-4928
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE STE 170
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4624
Practice Address - Country:US
Practice Address - Phone:623-249-4928
Practice Address - Fax:623-249-4971
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ139168Medicare PIN
SCAA40557951Medicare PIN