Provider Demographics
NPI:1447258728
Name:BALLENGER, FRED JACKSON (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:JACKSON
Last Name:BALLENGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2602 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1010
Mailing Address - Country:US
Mailing Address - Phone:540-344-1400
Mailing Address - Fax:540-344-7133
Practice Address - Street 1:2602 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1010
Practice Address - Country:US
Practice Address - Phone:540-344-1400
Practice Address - Fax:540-344-7133
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027649207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6091270Medicaid
VACG1162OtherRR MEDICARE GROUP
VACG1162OtherRR MEDICARE GROUP