Healthcare Provider Details

I. General information

NPI: 1881038735
Provider Name (Legal Business Name): SAMUEL JAMES BALLENTINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 SILAS DEANE HWY STE 101
WETHERSFIELD CT
06109-4337
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 860-859-9061
  • Fax: 860-889-6200
Mailing address:
  • Phone: 314-362-5641
  • Fax: 314-362-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2019024601
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: