Provider Demographics
NPI:1851314447
Name:BALLANTINE, EDWARD JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:BALLANTINE
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 1:56 KINGSBORO AVE
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-3411
Mailing Address - Country:US
Mailing Address - Phone:518-725-8834
Mailing Address - Fax:518-773-8551
Practice Address - Street 1:56 KINGSBORO AVE
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-3411
Practice Address - Country:US
Practice Address - Phone:518-725-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130238-1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00553484Medicaid
NY00553484Medicaid