Provider Demographics
NPI:1730275504
Name:BALLEW, C L
Entity type:Individual
Prefix:
First Name:C
Middle Name:L
Last Name:BALLEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ATRIUM WAY
Mailing Address - Street 2:SUITE 232
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6383
Mailing Address - Country:US
Mailing Address - Phone:803-788-8484
Mailing Address - Fax:803-788-8499
Practice Address - Street 1:115 ATRIUM WAY
Practice Address - Street 2:SUITE 232
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6383
Practice Address - Country:US
Practice Address - Phone:803-788-8484
Practice Address - Fax:803-788-8499
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1888208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1817Medicaid
SCP93660Medicare UPIN
SC8614Medicare PIN