Provider Demographics
NPI:1184776130
Name:BALLANTYNE MEDICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:BALLANTYNE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-540-1640
Mailing Address - Street 1:12311 COPPER WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3386
Mailing Address - Country:US
Mailing Address - Phone:704-540-1640
Mailing Address - Fax:704-540-1639
Practice Address - Street 1:12311 COPPER WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3386
Practice Address - Country:US
Practice Address - Phone:704-540-1640
Practice Address - Fax:704-540-1639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2329378Medicare PIN