Healthcare Provider Details

I. General information

NPI: 1497296685
Provider Name (Legal Business Name): MATTHEW BALLENBERGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

DEPT 3010, PO BOX 986524
BOSTON MA
02298-6524
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4070
  • Fax: 401-649-4071
Mailing address:
  • Phone: 833-924-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number73520
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD19716
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberMD19716
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD19716
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number306174
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: