Provider Demographics
NPI:1336113992
Name:BALAMUNISWAMY, LATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:LATHA
Middle Name:
Last Name:BALAMUNISWAMY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 19TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3700
Mailing Address - Country:US
Mailing Address - Phone:309-779-7050
Mailing Address - Fax:309-764-6269
Practice Address - Street 1:106 19TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3700
Practice Address - Country:US
Practice Address - Phone:309-779-7050
Practice Address - Fax:309-764-6269
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087173207Q00000X
IA34452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
036087173OtherBCILLINOIS
IA0575423Medicaid
IL036087173002Medicaid
IA1336113992Medicaid
IA1575423Medicaid
80193932OtherRR MEDICARE
IA719260583Medicare PIN
036087173OtherBCILLINOIS
L95520Medicare UPIN
IA0575423Medicaid