Provider Demographics
NPI:1952321341
Name:BALDEA, LIDIA C (MD)
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:C
Last Name:BALDEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIDIA
Other - Middle Name:C
Other - Last Name:ROLLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-365-0020
Mailing Address - Fax:864-365-0205
Practice Address - Street 1:10 ENTERPRISE BLVD STE 111
Practice Address - Street 2:COVENANT INTERNAL MEDICINE
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3534
Practice Address - Country:US
Practice Address - Phone:864-365-0200
Practice Address - Fax:864-365-0205
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC270496Medicaid
SC270496Medicaid
SCAA20537951Medicare PIN