Basic Information
| Provider Information | |||||||||
| NPI: | 1558749283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALASUBRAMANIAM | ||||||||
| FirstName: | ASHWIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | STE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2722 MERRILEE DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A167770 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0092289 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 0101272533 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.