Provider Demographics
NPI:1588753743
Name:BALLIS, EDWARD S (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
Last Name:BALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:115 W SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-3628
Mailing Address - Country:US
Mailing Address - Phone:413-568-2811
Mailing Address - Fax:413-572-5192
Practice Address - Street 1:115 W SILVER ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-3628
Practice Address - Country:US
Practice Address - Phone:413-568-2811
Practice Address - Fax:413-572-5192
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA765172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA076517OtherTUFTS
MA10418OtherHEALTH NEW ENGLAND
MAJ12956OtherBLUE CROSS BLUE SHIELD
MA3098281Medicaid
MAJ12956OtherBLUE CROSS BLUE SHIELD
MA3098281Medicaid