Basic Information
| Provider Information | |||||||||
| NPI: | 1598077679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALGURI | ||||||||
| FirstName: | SUMANTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OWEGO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076870350 | ||||||||
| FaxNumber: | 6076870333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2010 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-8115 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 27769 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 288945 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 198945001 | 05 | AR | MEDICAID |