MEDICARE: MANJULA BALASUBRAMANIAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	MD032700E	PA
2	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	MD032700E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336191683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANJULA BALASUBRAMANIAN MD

Provider Business Mailing Address
First Line	:	101 E OLNEY AVE
Second Line	:	STE 400
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-2470
Country	:	US
Telephone Number	:	215-255-7822
Fax Number	:	215-255-7825

Provider Business Practice Location Address
First Line	:	245 N 15TH ST
Second Line	:	MS 435
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1101
Country	:	US
Telephone Number	:	215-762-8873
Fax Number	:	215-762-3274

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	12/31/2019

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