Healthcare Provider Details

I. General information

NPI: 1215173372
Provider Name (Legal Business Name): ELLEN BALDINO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ASHLEY AVE
CHARLESTON SC
29401-1220
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4271
  • Fax: 843-792-0644
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1327
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: