Basic Information
| Provider Information | |||||||||
| NPI: | 1831304088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLERT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 KENTUCKY AVE | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704157653 | ||||||||
| FaxNumber: | 2705758359 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 KENTUCKY AVE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704084368 | ||||||||
| FaxNumber: | 2704083272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | ME104223 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | TP352 | KY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 7100138780 | 05 | KY | MEDICAID |