Individual
SALLY J BALLARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
200 S BROADWAY, GOREVILLE, IL 62939
(618) 995-2396
(618) 995-2947
Mailing address
200 S BROADWAY, PO BOX 40, GOREVILLE, IL 62939
(618) 995-2396
(618) 995-2947
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
215389
MEDICARE GROUP NUMBER
IL
Enumeration date
07/18/2007
Last updated
11/12/2007
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