Provider Demographics
NPI:1467409573
Name:BALLANTYNE, GARTH HADDEN (MD)
Entity Type:Individual
Prefix:
First Name:GARTH
Middle Name:HADDEN
Last Name:BALLANTYNE
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 1:20 PROSPECT AVE
Mailing Address - Street 2:SUITE 901
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1997
Mailing Address - Country:US
Mailing Address - Phone:201-996-2959
Mailing Address - Fax:201-996-3222
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 901
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-996-2959
Practice Address - Fax:201-996-3222
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65505174400000X
CT26835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD88712Medicare UPIN