Healthcare Provider Details

I. General information

NPI: 1023192291
Provider Name (Legal Business Name): EDGAR HENRY BALLENAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 SANDWICH ST
PLYMOUTH MA
02360-2183
US

IV. Provider business mailing address

198 CHURCH ST
MARSHFIELD MA
02050-1710
US

V. Phone/Fax

Practice location:
  • Phone: 508-830-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number71683
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: