Provider Demographics
NPI:1932336542
Name:BALLYAMANDA, SMITHA M (MD)
Entity Type:Individual
Prefix:
First Name:SMITHA
Middle Name:M
Last Name:BALLYAMANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:515 RIVERCROSSING DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7900
Mailing Address - Country:US
Mailing Address - Phone:803-578-2800
Mailing Address - Fax:803-578-2810
Practice Address - Street 1:515 RIVERCROSSING DR
Practice Address - Street 2:SUITE 180
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7900
Practice Address - Country:US
Practice Address - Phone:803-578-2800
Practice Address - Fax:803-578-2810
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2017-06-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC2016-02043207Q00000X, 207QS0010X
SC36544207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC365447Medicaid