Provider Demographics
NPI:1780626143
Name:BALASUBRAMANIAN, KANCHANA (MD)
Entity type:Individual
Prefix:DR
First Name:KANCHANA
Middle Name:
Last Name:BALASUBRAMANIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WALTER CT
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2558
Mailing Address - Country:US
Mailing Address - Phone:201-893-2939
Mailing Address - Fax:201-460-0770
Practice Address - Street 1:6 WALTER CT
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2558
Practice Address - Country:US
Practice Address - Phone:201-893-2939
Practice Address - Fax:201-460-0770
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07605600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0016497Medicaid
NJ11266126OtherCAQH
NJ071264RWXMedicare ID - Type UnspecifiedMEDICARE ID #
NJ0016497Medicaid
NJ11266126OtherCAQH