Basic Information
| Provider Information | |||||||||
| NPI: | 1922057900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDARAM | ||||||||
| FirstName: | BALASASIKUMAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1543 FIANNA PLACE TER | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729088582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796486714 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 TOWSON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729014921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794415011 | ||||||||
| FaxNumber: | 4794414932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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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 | 207P00000X | E4251 | AR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 156990001 | 05 | AR | MEDICAID | E4251 | 01 | AZ | ARKANSAS STATE LICENSE | OTHER | 200117580A | 05 | OK | MEDICAID | BS7443017 | 01 | AZ | DEA | OTHER |