1407843022 NPI number — ELANGOVAN BALAKRISHNAN MD

Table of content: ELANGOVAN BALAKRISHNAN MD (NPI 1407843022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407843022 NPI number — ELANGOVAN BALAKRISHNAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALAKRISHNAN
Provider First Name:
ELANGOVAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407843022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 E BROADWAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65201-7167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-874-7800
Provider Business Mailing Address Fax Number:
573-443-3627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 E BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65201-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-874-7800
Provider Business Practice Location Address Fax Number:
573-443-3627
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  2004024397 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5132415 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 65201A011 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 22604 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 689969 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 193438 . This is a "BCBS OF MO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209024306 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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