Basic Information
| Provider Information | |||||||||
| NPI: | 1831350446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALASUBRAMANIAM | ||||||||
| FirstName: | BALAMURALI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 COLD SPRING RD APT 215 | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060673129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542636809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2008 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | P1725 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8DC790 | 01 | TX | BCBS-TX | OTHER | P1725 | 01 | TX | STATE LICENSE | OTHER | 1831350446 | 01 | TX | TRICARE - SOUTH | OTHER | 297419801 | 05 | TX | MEDICAID |