Provider Demographics
NPI:1891724951
Name:KRISHNIAH, BALASUBRAMANYAM (MD)
Entity Type:Individual
Prefix:
First Name:BALASUBRAMANYAM
Middle Name:
Last Name:KRISHNIAH
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 1:300 W BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2538
Mailing Address - Country:US
Mailing Address - Phone:864-277-8300
Mailing Address - Fax:864-288-8722
Practice Address - Street 1:300 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2538
Practice Address - Country:US
Practice Address - Phone:864-277-8300
Practice Address - Fax:864-288-8722
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC196521Medicaid
SC7761Medicare PIN
SC196521Medicaid