Basic Information
| Provider Information | |||||||||
| NPI: | 1932395811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALAMUTHUSAMY | ||||||||
| FirstName: | SARAVANAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775858 | ||||||||
| FaxNumber: | 8173354418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775858 | ||||||||
| FaxNumber: | 8173354418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 201657 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | Q2427 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 20565 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 43632 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | Q2427 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 342884901 | 05 | TX | MEDICAID |