Provider Demographics
NPI:1144304874
Name:BALLOU, CAROL (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BALLOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-0261
Mailing Address - Country:US
Mailing Address - Phone:630-321-9590
Mailing Address - Fax:630-986-1477
Practice Address - Street 1:501 W OGDEN AVE STE 6
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3184
Practice Address - Country:US
Practice Address - Phone:630-321-9590
Practice Address - Fax:630-920-0931
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0583292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL022-26656OtherBLUE CROSS BLUE SHIELD
IL022-26656OtherBLUE CROSS BLUE SHIELD