Provider Demographics
NPI:1497890750
Name:IYER, BALASUBRAMANIAM S (MD)
Entity Type:Individual
Prefix:DR
First Name:BALASUBRAMANIAM
Middle Name:S
Last Name:IYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:B
Other - Middle Name:S
Other - Last Name:IYER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1945 W WILSON AVENUE
Mailing Address - Street 2:SUITE #2115
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-878-5225
Mailing Address - Fax:773-878-5661
Practice Address - Street 1:1945 W WILSON AVENUE
Practice Address - Street 2:SUITE #2115
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-878-5225
Practice Address - Fax:773-878-5661
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360461652086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36046165Medicaid
211814Medicare UPIN