Provider Demographics
NPI:1992904338
Name:PETER G BALLAS II MD PA
Entity type:Organization
Organization Name:PETER G BALLAS II MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:BALLAS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD PA
Authorized Official - Phone:561-989-9002
Mailing Address - Street 1:1905 CLINT MOORE RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2658
Mailing Address - Country:US
Mailing Address - Phone:561-989-9002
Mailing Address - Fax:561-994-9135
Practice Address - Street 1:1905 CLINT MOORE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2658
Practice Address - Country:US
Practice Address - Phone:561-989-9002
Practice Address - Fax:561-994-9135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54253Medicare UPIN