Basic Information
| Provider Information | |||||||||
| NPI: | 1730184789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLOU | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRICK | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249860457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 8669036621 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ARH LANE | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | LOW MOOR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244570007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408626710 | ||||||||
| FaxNumber: | 5408629167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 0101036698 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 006099483 | 05 | VA | MEDICAID |