Basic Information
| Provider Information | |||||||||
| NPI: | 1093017253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALA | ||||||||
| FirstName: | KAMALESH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653311720 | ||||||||
| FaxNumber: | 8653312823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653311720 | ||||||||
| FaxNumber: | 8653312823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2010 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | P69451 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 0101273972 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 40545 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 58677 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1093017253 | 05 | IA | MEDICAID | Q046659 | 05 | TN | MEDICAID | 509280003 | 01 | IA | MEDICARE PTAN | OTHER |