Provider Demographics
NPI:1528176393
Name:BALL, CONNIE S (MD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:S
Last Name:BALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:562 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9552
Mailing Address - Country:US
Mailing Address - Phone:937-748-5346
Mailing Address - Fax:937-748-5369
Practice Address - Street 1:66 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-1138
Practice Address - Country:US
Practice Address - Phone:937-748-5346
Practice Address - Fax:937-748-5369
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0168894Medicaid
000000338258OtherANTHEM BCBS
0112593OtherUNITED HEALTHCARE
D67559OtherHUMANA
3836999415668002OtherAETNA
363899941026OtherCARESOURCE
OH4131751Medicare ID - Type Unspecified
363899941026OtherCARESOURCE