Provider Demographics
NPI:1295720001
Name:VENGALIL, SHYLA R (MD)
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:R
Last Name:VENGALIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22151 MOROSS RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2167
Mailing Address - Country:US
Mailing Address - Phone:313-343-7374
Mailing Address - Fax:313-343-7072
Practice Address - Street 1:22151 MOROSS RD
Practice Address - Street 2:SUITE 320
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2167
Practice Address - Country:US
Practice Address - Phone:313-343-7374
Practice Address - Fax:313-343-7072
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056978207VM0101X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4408530OtherECFMG
MIM71670083Medicare PIN
G15399Medicare UPIN
M71670083Medicare ID - Type Unspecified
MI3436484Medicaid
G15399Medicare UPIN