Provider Demographics
NPI:1689845687
Name:BALASUBRAMANIAN, SOWMYA (MD)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:BALASUBRAMANIAN
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:11TH FLOOR CS MOTT CHILDRENS HOSPITAL ROOM 661
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-764-5176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235843208000000X, 2080P0202X
MI4301113639208000000X, 2080P0202X
CAA1219372080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine