Healthcare Provider Details

I. General information

NPI: 1649427436
Provider Name (Legal Business Name): CAROLYN O. BALLANTINE, MD. PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 LEGION RD SUITE 224
CHAPEL HILL NC
27517-2375
US

IV. Provider business mailing address

1709 LEGION RD SUITE 224
CHAPEL HILL NC
27517-2375
US

V. Phone/Fax

Practice location:
  • Phone: 919-593-5548
  • Fax: 919-929-8900
Mailing address:
  • Phone: 919-593-5548
  • Fax: 919-929-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200201134
License Number StateNC

VIII. Authorized Official

Name: DR. CAROLYN OATES BALLANTINE
Title or Position: SOLE MEMBER/ORGANIZER
Credential: MD
Phone: 919-593-5548