Healthcare Provider Details

I. General information

NPI: 1902814049
Provider Name (Legal Business Name): BANGURA MEDICAL SERVICES,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 EXECUTIVE DR STE G
LAFAYETTE IN
47905-4867
US

IV. Provider business mailing address

13 S BROOKFIELD DR
LAFAYETTE IN
47905-7658
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4646
  • Fax: 765-448-4791
Mailing address:
  • Phone: 765-447-7941
  • Fax: 765-447-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01045193A
License Number StateIN

VIII. Authorized Official

Name: LUELLA BANGURA
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 765-447-7941