Healthcare Provider Details

I. General information

NPI: 1326095548
Provider Name (Legal Business Name): VAIDYANATHAPURAM BALAKRISHNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 03/11/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST. SUITE 202 SEMC - MEDICAL SPECIALTIES PRACTICE
BRIGHTON MA
02135
US

IV. Provider business mailing address

BMCHS PROVIDER ENROLLMENT 960 MASSACHUSETTS AVE FLR 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-779-6700
  • Fax: 617-779-6771
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number204354
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: