Provider Demographics
NPI:1174569511
Name:BALLENGER, THOMAS (MSPT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BALLENGER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 RISING SUN TOWN CTR
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1902
Practice Address - Country:US
Practice Address - Phone:410-658-0100
Practice Address - Fax:410-658-0199
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001666225100000X
MD20892225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5070-0024OtherCARE FIRST
61809001OtherNCA
DE1174569511Medicaid
PA2410592000OtherAMERIHEALTH
DE1174569511Medicaid
P64823Medicare UPIN
DE009970F60Medicare ID - Type Unspecified
MD313PR209Medicare PIN
61809001OtherNCA
PA2410592000OtherAMERIHEALTH
MD552MG664Medicare ID - Type Unspecified