Provider Demographics
NPI:1912996505
Name:BALLARD, PHILLIP W (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:W
Last Name:BALLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1624
Mailing Address - Country:US
Mailing Address - Phone:719-538-2950
Mailing Address - Fax:719-538-2996
Practice Address - Street 1:2610 TENDERFOOT HILL ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-576-3901
Practice Address - Fax:719-576-2025
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00238712084N0400X, 2084P0800X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01238716Medicaid
COD24338Medicare UPIN
CO01238716Medicaid