Provider Demographics
NPI:1669656112
Name:ID CARE PC
Entity Type:Organization
Organization Name:ID CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KALYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:VANGALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-364-5590
Mailing Address - Street 1:1800 BRAMBLE DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1730
Mailing Address - Country:US
Mailing Address - Phone:517-364-5590
Mailing Address - Fax:
Practice Address - Street 1:1808 S PENNSYLVANIA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1897
Practice Address - Country:US
Practice Address - Phone:517-371-1500
Practice Address - Fax:517-371-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110C315710OtherBCBSM
MIH56529Medicare UPIN
MI0P52370Medicare PIN