Healthcare Provider Details

I. General information

NPI: 1760514517
Provider Name (Legal Business Name): M. BALASUBRAMANIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MANI BALA MD

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E STATE PKWY
SCHAUMBURG IL
60173-4538
US

IV. Provider business mailing address

506 E STATE PKWY
SCHAUMBURG IL
60173-4538
US

V. Phone/Fax

Practice location:
  • Phone: 847-885-5220
  • Fax: 847-755-5170
Mailing address:
  • Phone: 847-885-5220
  • Fax: 847-755-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number36046825
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberC139181
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberLT17656
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: