Provider Demographics
NPI:1669554382
Name:PISUPATI, BALASUBRAMANIYAM (RPT)
Entity type:Individual
Prefix:
First Name:BALASUBRAMANIYAM
Middle Name:
Last Name:PISUPATI
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3971
Mailing Address - Country:US
Mailing Address - Phone:517-990-1242
Mailing Address - Fax:
Practice Address - Street 1:3235 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3971
Practice Address - Country:US
Practice Address - Phone:517-990-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007541225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P01940Medicare PIN
Q27237Medicare UPIN