Provider Demographics
NPI:1205935731
Name:BALASANDIRAN, EMIL ANTONINE (MD)
Entity type:Individual
Prefix:
First Name:EMIL
Middle Name:ANTONINE
Last Name:BALASANDIRAN
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 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1406 W BELLA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5229
Practice Address - Country:US
Practice Address - Phone:765-660-7720
Practice Address - Fax:765-662-4493
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000742788OtherANTHEM
IN100124430Medicaid
INM400062125Medicare PIN
IN000000742788OtherANTHEM