Healthcare Provider Details

I. General information

NPI: 1043479116
Provider Name (Legal Business Name): AMRUTHA BALAKRISHNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BOLTON ST
MARLBOROUGH MA
01752-3999
US

IV. Provider business mailing address

PO BOX 41538
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-481-0200
  • Fax: 508-229-2343
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD71971
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number277278
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: