Provider Demographics
NPI:1881685550
Name:SRIDHARAN, BALAKRISHNAN (MD)
Entity Type:Individual
Prefix:
First Name:BALAKRISHNAN
Middle Name:
Last Name:SRIDHARAN
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 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:HOSPITALISTS PROGRAM
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:304-388-9654
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19265207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1809060000Medicaid
WVP00824219OtherRAILROAD MEDICARE
WV3810016539Medicaid
WV1809060000Medicaid
WV3810016539Medicaid
SR4096502Medicare PIN