Basic Information
| Provider Information | |||||||||
| NPI: | 1033197629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUBBIAH | ||||||||
| FirstName: | BAKKIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135856200 | ||||||||
| FaxNumber: | 5132453672 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758730 | ||||||||
| FaxNumber: | 5134758033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 036049109 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 35123625 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 19525 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | ME88557 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 19525 | IA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 036049109 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 35123625 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | ME88557 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | IL0136 | 01 | IL | JOHN DEERE FAMILY | OTHER | 20957 | 01 | WELLMARK | OTHER | IA0151 | 01 | IA | JOHN DEERE FAMILY | OTHER | 8121085 | 01 | IL | BCBS | OTHER | 036049109 | 05 | IL | MEDICAID | 050739 | 01 | HEALTH ALLIANCE | OTHER | 15929 | 01 | MIDLANDS CHOICE | OTHER | 20068 | 01 | IA HEALTH SOLUTIONS | OTHER | 686137 | 01 | FIRST HEALTH | OTHER | 1996108 | 05 | IA | MEDICAID | 97295 | 01 | WELLMARK | OTHER |