Provider Demographics
NPI:1114934759
Name:BALLINGER, KEITH E (PA C)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:E
Last Name:BALLINGER
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-543-3751
Practice Address - Street 1:1000 HEALTH CENTER DR STE 305
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-258-4186
Practice Address - Fax:217-348-4185
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001872363A00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208512Medicare ID - Type Unspecified
IL247290Medicare ID - Type UnspecifiedGRP NUMBER
P76091Medicare UPIN