Healthcare Provider Details

I. General information

NPI: 1114934759
Provider Name (Legal Business Name): KEITH E. BALLINGER PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DR STE 305
MATTOON IL
61938-4644
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-4186
  • Fax: 217-348-4185
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001872
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number085001872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: