Provider Demographics
NPI:1871580779
Name:BALLANTINE, PERCY (MD)
Entity type:Individual
Prefix:
First Name:PERCY
Middle Name:
Last Name:BALLANTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ANNA MARSH LANE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0803
Mailing Address - Country:US
Mailing Address - Phone:802-257-7785
Mailing Address - Fax:
Practice Address - Street 1:ANNA MARSH LANE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05302-0803
Practice Address - Country:US
Practice Address - Phone:802-257-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0005715103TB0200X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT 0006779Medicaid
VTVT9884Medicare ID - Type Unspecified
VTVT 0006779Medicaid