Basic Information
| Provider Information | |||||||||
| NPI: | 1245215953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLARD, III | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787412317 | ||||||||
| FaxNumber: | 7709444522 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 CANTON RD NE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300608948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704290031 | ||||||||
| FaxNumber: | 6788194299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 022509 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 000225178G | 05 | GA | MEDICAID |