Provider Demographics
NPI:1629234141
Name:BALLENTINE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:BALLENTINE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:NICOLA
Authorized Official - Last Name:GEURKINK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-732-0920
Mailing Address - Street 1:11134 BROAD RIVER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-9668
Mailing Address - Country:US
Mailing Address - Phone:803-732-0920
Mailing Address - Fax:803-227-2759
Practice Address - Street 1:11134 BROAD RIVER RD
Practice Address - Street 2:SUITE D
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-9668
Practice Address - Country:US
Practice Address - Phone:803-732-0920
Practice Address - Fax:803-227-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC195002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC195005Medicaid