MEDICARE: SUDHA BANSAL MD 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1174898498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUDHA BANSAL MD PC

Provider Business Mailing Address
First Line	:	PO BOX 1476
Second Line	:
City	:	ADRIAN
State	:	MI
Zip	:	49221-7476
Country	:	US
Telephone Number	:	517-264-5820
Fax Number	:	517-264-0311

Provider Business Practice Location Address
First Line	:	415 MILL RD
Second Line	:
City	:	ADRIAN
State	:	MI
Zip	:	49221-1764
Country	:	US
Telephone Number	:	517-264-5820
Fax Number	:	517-264-0311

Authorized Official
Title or Position	:	OWNER
Name	:	SUDHA BANSAL
Credential	:	M.D.
Telephone Number	:	517-264-5820

Provider Enumeration Date	:	03/20/2012
Last Update Date	:	03/20/2012

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