Provider Demographics
NPI:1629332218
Name:VIJAYA CHALLA, M.D.P.C.
Entity Type:Organization
Organization Name:VIJAYA CHALLA, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIA
Authorized Official - Prefix:
Authorized Official - First Name:VIJAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-449-5456
Mailing Address - Street 1:7445 ALLEN RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:SUITE 180
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1963
Practice Address - Country:US
Practice Address - Phone:810-449-5456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVC080035261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4865150Medicaid
MII52277Medicare UPIN
N98520004Medicare PIN