Healthcare Provider Details

I. General information

NPI: 1467409573
Provider Name (Legal Business Name): GARTH HADDEN BALLANTYNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE SUITE 901
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

20 PROSPECT AVE SUITE 901
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-2959
  • Fax: 201-996-3222
Mailing address:
  • Phone: 201-996-2959
  • Fax: 201-996-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA65505
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number26835
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: