Basic Information
| Provider Information | |||||||||
| NPI: | 1275551160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLO | ||||||||
| FirstName: | BELA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1789 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543033243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204997080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1789 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543033243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204997080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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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 | 2085R0202X | 35-06-8549 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 4301116279 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 54055 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | K400134453 | 01 | WI | PTAN | OTHER | 176902 | 05 | OH | MEDICAID |