Provider Demographics
NPI:1477748960
Name:BALASUNDARAM, MILTON J (PT)
Entity Type:Individual
Prefix:MR
First Name:MILTON
Middle Name:J
Last Name:BALASUNDARAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54014 STARLITE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1540
Mailing Address - Country:US
Mailing Address - Phone:248-425-5455
Mailing Address - Fax:
Practice Address - Street 1:54014 STARLITE DR
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1540
Practice Address - Country:US
Practice Address - Phone:248-425-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-08
Last Update Date:2019-08-28
Deactivation Date:2008-08-07
Deactivation Code:
Reactivation Date:2010-04-02
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501007447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F338120OtherMI BLUE CROSS/BLUE SHIELD
MIP40780003Medicare PIN