Provider Demographics
NPI:1053286815
Name:EVOLUTIONARY HEALTHCARE WEST VIRGINIA PLLC
Entity type:Organization
Organization Name:EVOLUTIONARY HEALTHCARE WEST VIRGINIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUSSIEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BALLOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-387-9451
Mailing Address - Street 1:1931 19TH PL
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3555
Mailing Address - Country:US
Mailing Address - Phone:321-387-9451
Mailing Address - Fax:
Practice Address - Street 1:3006 MOUNT VERNON RD STE 1075
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-0318
Practice Address - Country:US
Practice Address - Phone:321-387-9451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty