Provider Demographics
NPI:1255775268
Name:BALU, SRIRAM (PA-C)
Entity type:Individual
Prefix:DR
First Name:SRIRAM
Middle Name:
Last Name:BALU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:DR
Other - First Name:SRIRAM
Other - Middle Name:
Other - Last Name:BALU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA-C
Mailing Address - Street 1:297 CHARLOTTE CT
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-8394
Mailing Address - Country:US
Mailing Address - Phone:717-643-0739
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant