Basic Information
| Provider Information | |||||||||
| NPI: | 1619956042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALAKRISHNAN | ||||||||
| FirstName: | BINOD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC CRITICAL CARE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663360 | ||||||||
| FaxNumber: | 4142663563 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | PEDIATRIC CRITICAL CARE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663360 | ||||||||
| FaxNumber: | 4142663563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 208000000X | 01061489A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 56818 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 56818 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619956042 | 05 | WI | MEDICAID | 200544850 | 05 | IN | MEDICAID |