Basic Information
| Provider Information | |||||||||
| NPI: | 1538119557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2853 HEALTH PARKWAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488583872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897757641 | ||||||||
| FaxNumber: | 9897756472 | ||||||||
| Practice Location | |||||||||
| Address1: | 2853 HEALTH PARKWAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488583872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897757641 | ||||||||
| FaxNumber: | 9897756472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/19/2006 | ||||||||
| NPIReactivationDate: | 06/14/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101012938 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200000005465 | 01 | MI | HEALTHPLUS | OTHER | 4321248-11 | 05 | MI | MEDICAID | 01-01951 | 01 | MI | PHP COMMERCIAL | OTHER | 0153700165 | 01 | MI | BCBS | OTHER | 1006927 | 01 | MI | MCLAREN HEALTH PLAN | OTHER |