Provider Demographics
NPI:1437250933
Name:BALLENGEE, GREGORY BRUCE (MD)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:BRUCE
Last Name:BALLENGEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 WIND CHIME LANE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415
Mailing Address - Country:US
Mailing Address - Phone:814-835-1756
Mailing Address - Fax:814-452-4174
Practice Address - Street 1:215 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507
Practice Address - Country:US
Practice Address - Phone:814-453-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056573L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1537370Medicaid
BA158881Medicare ID - Type Unspecified
PA1537370Medicaid