Healthcare Provider Details

I. General information

NPI: 1891724951
Provider Name (Legal Business Name): BALASUBRAMANYAM KRISHNIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BUTLER RD
MAULDIN SC
29662-2538
US

IV. Provider business mailing address

300 W BUTLER RD
MAULDIN SC
29662-2538
US

V. Phone/Fax

Practice location:
  • Phone: 864-277-8300
  • Fax: 864-288-8722
Mailing address:
  • Phone: 864-277-8300
  • Fax: 864-288-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19652
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: