Healthcare Provider Details

I. General information

NPI: 1437250933
Provider Name (Legal Business Name): GREGORY BRUCE BALLENGEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 HOLLAND ST
ERIE PA
16507
US

IV. Provider business mailing address

5804 WIND CHIME LANE
FAIRVIEW PA
16415
US

V. Phone/Fax

Practice location:
  • Phone: 814-453-5058
  • Fax:
Mailing address:
  • Phone: 814-835-1756
  • Fax: 814-452-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD056573L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: