1336191683 NPI number — MANJULA BALASUBRAMANIAN MD

Table of content: MANJULA BALASUBRAMANIAN MD (NPI 1336191683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336191683 NPI number — MANJULA BALASUBRAMANIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALASUBRAMANIAN
Provider First Name:
MANJULA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1336191683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E OLNEY AVE
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19120-2470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-255-7822
Provider Business Mailing Address Fax Number:
215-255-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 N 15TH ST
Provider Second Line Business Practice Location Address:
MS 435
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-762-8873
Provider Business Practice Location Address Fax Number:
215-762-3274
Provider Enumeration Date:
05/16/2006

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: 207ZP0102X , with the licence number:  MD032700E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0105X , with the licence number: MD032700E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001248171 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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