Healthcare Provider Details

I. General information

NPI: 1689619025
Provider Name (Legal Business Name): BALASUBRAMAN SRINIVASAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E HANNUM BLVD
SAGINAW MI
48602-1910
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 989-776-8033
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BALASUBRAMANIAM SRINIVASAN
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 989-776-8033