Provider Demographics
NPI:1841781952
Name:BALLIS, STEPHEN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DANIEL
Last Name:BALLIS
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:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVENUE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-792-8972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52438208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics