MEDICARE: DR. SUDHA BANSAL M.D.

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	207Q00000X	Family Medicine Physician	4301404631	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922053008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHA BANSAL M.D.

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	:

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	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	03/14/2012

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