Provider Demographics
NPI:1376804971
Name:BALLANTYNE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:BALLANTYNE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-208-4134
Mailing Address - Street 1:16147 LANCASTER HWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4782
Mailing Address - Country:US
Mailing Address - Phone:704-208-4134
Mailing Address - Fax:704-248-7845
Practice Address - Street 1:16147 LANCASTER HWY
Practice Address - Street 2:SUITE 140
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4782
Practice Address - Country:US
Practice Address - Phone:704-208-4134
Practice Address - Fax:704-248-7845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-01795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty