Healthcare Provider Details

I. General information

NPI: 1669656112
Provider Name (Legal Business Name): ID CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 S PENNSYLVANIA AVE SUITE E
LANSING MI
48910-1897
US

IV. Provider business mailing address

1800 BRAMBLE DR
EAST LANSING MI
48823-1730
US

V. Phone/Fax

Practice location:
  • Phone: 517-371-1500
  • Fax: 517-371-1501
Mailing address:
  • Phone: 517-364-5590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: KALYANI VANGALA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 517-364-5590