Healthcare Provider Details

I. General information

NPI: 1073594693
Provider Name (Legal Business Name): GANESH R BALU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 BEISER BLVD SUITE 201
DOVER DE
19904-8208
US

IV. Provider business mailing address

240 BEISER BLVD SUITE 201
DOVER DE
19904-8208
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-7246
  • Fax: 302-678-8890
Mailing address:
  • Phone: 302-734-7246
  • Fax: 302-678-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License NumberC1-0005467
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberC1-0005467
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberC1-0005467
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: