MEDICARE: PADMINI BALAGOPAL PH.D RD CDE IBCLC

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	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1902231517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PADMINI BALAGOPAL PH.D RD CDE IBCLC

Provider Business Mailing Address
First Line	:	1901 JFK BLVD
Second Line	:	APT. 802
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1502
Country	:	US
Telephone Number	:	848-219-9858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1641 W GIRARD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-1614
Country	:	US
Telephone Number	:	848-219-9858
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2013
Last Update Date	:	09/13/2013

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