Healthcare Provider Details

I. General information

NPI: 1396786273
Provider Name (Legal Business Name): JAY SHANKAR BALACHANDRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13133 N PORT WASHINGTON RD SUITE 104
MEQUON WI
53097-2419
US

IV. Provider business mailing address

788 N JEFFERSON ST SUITE 300/ATTN. KAAREN BUTZEN
MILWAUKEE WI
53202-3718
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-5044
  • Fax: 262-243-2510
Mailing address:
  • Phone: 414-272-8950
  • Fax: 414-272-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number64930
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number64930
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number64930
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: