Provider Demographics
NPI:1760514517
Name:BALASUBRAMANIAN, M. (MD)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:
Last Name:BALASUBRAMANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MANI
Other - Middle Name:
Other - Last Name:BALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:506 E STATE PKWY
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4538
Mailing Address - Country:US
Mailing Address - Phone:847-885-5220
Mailing Address - Fax:847-755-5170
Practice Address - Street 1:506 E STATE PKWY
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4538
Practice Address - Country:US
Practice Address - Phone:847-885-5220
Practice Address - Fax:847-755-5170
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36046825207ZP0101X
CAC139181207ND0900X
NDLT17656207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK00118Medicare ID - Type Unspecified
ILH39861Medicare UPIN