1831350446 NPI number — BALAMURALI BALASUBRAMANIAM M.D.

Table of content: BALAMURALI BALASUBRAMANIAM M.D. (NPI 1831350446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831350446 NPI number — BALAMURALI BALASUBRAMANIAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALASUBRAMANIAM
Provider First Name:
BALAMURALI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1831350446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 COLD SPRING RD APT 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-3129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-263-6809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-679-4017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2008

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: P1725 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8DC790 . This is a "BCBS-TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P1725 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1831350446 . This is a "TRICARE - SOUTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 297419801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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