Basic Information
Provider Information | |||||||||
NPI: | 1174886832 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALLEW | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 2ND ST NE | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200028100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028530091 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2000 E GREENVILLE ST | ||||||||
Address2: | SUITE 3700 | ||||||||
City: | ANDERSON | ||||||||
State: | SC | ||||||||
PostalCode: | 296211580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645121475 | ||||||||
FaxNumber: | 8645121930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2012 | ||||||||
LastUpdateDate: | 02/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1593 | SC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.