Healthcare Provider Details

I. General information

NPI: 1881180412
Provider Name (Legal Business Name): PALANIKUMAR BALASUNDARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 E RIVERSIDE BLVD
ROCKFORD IL
61114-2300
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-7000
  • Fax:
Mailing address:
  • Phone: 718-904-4105
  • Fax: 718-904-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036163854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: