MEDICARE: M BALASUBRAMANIAN MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	10258	NV

General Provider Information

NPI Number	:	1568540680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M BALASUBRAMANIAN MD INC

Provider Business Mailing Address
First Line	:	5375 S FORT APACHE RD
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7623
Country	:	US
Telephone Number	:	702-597-1597
Fax Number	:	702-736-1284

Provider Business Practice Location Address
First Line	:	5375 S FORT APACHE RD
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7623
Country	:	US
Telephone Number	:	702-597-1597
Fax Number	:	702-736-1284

Authorized Official
Title or Position	:	OWNER
Name	:	MAHESWARI J BALASUBRAMAINA
Credential	:	MD
Telephone Number	:	702-597-1597

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	08/22/2020

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