Provider Demographics
NPI:1376873760
Name:SOUMYA MADALA MD PLLC
Entity Type:Organization
Organization Name:SOUMYA MADALA MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOUMYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-339-0322
Mailing Address - Street 1:3937 PATIENT CARE DRIVE
Mailing Address - Street 2:#102
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-887-6763
Mailing Address - Fax:
Practice Address - Street 1:3937 PATIENT CARE WAY STE 102
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4287
Practice Address - Country:US
Practice Address - Phone:517-887-6763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085495207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty