Provider Demographics
NPI:1902814049
Name:BANGURA MEDICAL SERVICES,PC
Entity Type:Organization
Organization Name:BANGURA MEDICAL SERVICES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-447-7941
Mailing Address - Street 1:13 S BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7658
Mailing Address - Country:US
Mailing Address - Phone:765-447-7941
Mailing Address - Fax:765-447-4206
Practice Address - Street 1:5 EXECUTIVE DR STE G
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4867
Practice Address - Country:US
Practice Address - Phone:765-448-4646
Practice Address - Fax:765-448-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045193A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200421310AMedicaid
IN216380Medicare ID - Type Unspecified