MEDICARE: GHANSHYAM LALLA & PUSHPA LALLA PC

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	207RH0000X	Hematology (Internal Medicine) Physician	25819	NJ
2	207Q00000X	Family Medicine Physician	26258	NJ

General Provider Information

NPI Number	:	1639381858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GHANSHYAM LALLA & PUSHPA LALLA PC

Provider Business Mailing Address
First Line	:	383 NORTHFIELD AVE
Second Line	:	SUITE 102
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-3024
Country	:	US
Telephone Number	:	973-736-7750
Fax Number	:	973-669-9691

Provider Business Practice Location Address
First Line	:	383 NORTHFIELD AVE
Second Line	:	SUITE 102
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-3024
Country	:	US
Telephone Number	:	973-736-7750
Fax Number	:	973-669-9691

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GHANSHYAM S LALLA
Credential	:	MD
Telephone Number	:	973-736-7750

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	10/21/2010

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