Provider Demographics
NPI:1386898443
Name:BALA FAMILY PRACTICE
Entity type:Organization
Organization Name:BALA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRIRAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:BALASUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-569-1001
Mailing Address - Street 1:2021B EMMORTON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-8980
Mailing Address - Country:US
Mailing Address - Phone:410-569-1001
Mailing Address - Fax:141-056-9156
Practice Address - Street 1:2021B EMMORTON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-8980
Practice Address - Country:US
Practice Address - Phone:410-569-1001
Practice Address - Fax:410-569-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD52279261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD793302900Medicaid
MD793302900Medicaid