Basic Information
| Provider Information | |||||||||
| NPI: | 1932156874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLAY | ||||||||
| FirstName: | TEREASA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 S GLYNN ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704614126 | ||||||||
| FaxNumber: | 7704618852 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 S GLYNN ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704614126 | ||||||||
| FaxNumber: | 7704618852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 056027 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 591336957A | 05 | GA | MEDICAID |