Provider Demographics
NPI:1710986088
Name:BALASUBRAMONY, SURESH (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:BALASUBRAMONY
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 1:186 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26147-7100
Mailing Address - Country:US
Mailing Address - Phone:304-354-9244
Mailing Address - Fax:304-354-9323
Practice Address - Street 1:186 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26147-7100
Practice Address - Country:US
Practice Address - Phone:304-354-9244
Practice Address - Fax:304-354-9323
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1808807-000Medicaid
BA7306591Medicare ID - Type Unspecified
WV1808807-000Medicaid