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General NPI Number Information
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NPI Number | 1316100258
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Entity Type | Individual
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Provider Name | SUDARSHAN BALLA M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/09/2008
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Last Update Date | 05/16/2018
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Provider Practice Location Address
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Address Line | 1 HOSPTIAL DR DC095
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City | COLUMBIA
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State | MO
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Zip | 65212
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Country | US
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Telephone | 573-884-2123
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Fax | 573-884-2168
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Provider Business Mailing Address
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Address Line | 1 MEDICAL CENTER DR
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City | MORGANTOWN
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State | WV
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Zip | 26506-1200
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Country | US
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Telephone | 304-598-4000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2008013469
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 27816
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License Number State | WV
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