Basic Information
| Provider Information | |||||||||
| NPI: | 1912996505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382950 | ||||||||
| FaxNumber: | 7195382996 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 TENDERFOOT HILL ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195763901 | ||||||||
| FaxNumber: | 7195762025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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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 | 2084N0400X | DR.0023871 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | DR.0023871 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207Q00000X | DR.0023871 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01238716 | 05 | CO | MEDICAID |