Healthcare Provider Details

I. General information

NPI: 1063030021
Provider Name (Legal Business Name): ADITHYA BALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE BLDG 3
ROCHESTER NY
14621-3095
US

IV. Provider business mailing address

1632 STONE ST
SAGINAW MI
48602
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4000
  • Fax:
Mailing address:
  • Phone: 989-583-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4351049961
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4351049961
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: