Provider Demographics
NPI:1518062298
Name:KRISHNAN, BALAMURUGAN G (MD)
Entity Type:Individual
Prefix:
First Name:BALAMURUGAN
Middle Name:G
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 RENEE AVE
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2030
Mailing Address - Country:US
Mailing Address - Phone:573-776-1270
Mailing Address - Fax:
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-778-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.075327207R00000X, 207RG0300X, 208M00000X
MI4301067429207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine