Basic Information
| Provider Information | |||||||||
| NPI: | 1700972833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLINGER | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322740 | ||||||||
| FaxNumber: | 6183328755 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 BOND AVE | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622072328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183322740 | ||||||||
| FaxNumber: | 6183328755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036072705 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036072705 | 05 | IL | MEDICAID |