Provider Demographics
NPI:1316265184
Name:GULLA BALA KRISHNA MD PC
Entity type:Organization
Organization Name:GULLA BALA KRISHNA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GULLA
Authorized Official - Middle Name:BALA
Authorized Official - Last Name:KRISHNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-455-6626
Mailing Address - Street 1:PO BOX 409907
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9907
Mailing Address - Country:US
Mailing Address - Phone:888-462-1321
Mailing Address - Fax:615-261-6806
Practice Address - Street 1:705 NW ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3576
Practice Address - Country:US
Practice Address - Phone:931-455-6626
Practice Address - Fax:931-455-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10534208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB02989Medicare UPIN