Basic Information
| Provider Information | |||||||||
| NPI: | 1720025174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLAST | ||||||||
| FirstName: | CHRISTIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 E STATE ROAD 44 | ||||||||
| Address2: | STE A | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461764057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174212012 | ||||||||
| FaxNumber: | 3173981852 | ||||||||
| Practice Location | |||||||||
| Address1: | 2158 INTELLIPLEX DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173923651 | ||||||||
| FaxNumber: | 3173980538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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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 | 207R00000X | 01038703A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 01038703A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100317710 | 05 | IN | MEDICAID |