Provider Demographics
NPI:1881928455
Name:SAILAJA DATLA MD PLC
Entity type:Organization
Organization Name:SAILAJA DATLA MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAILAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:DATLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-445-3706
Mailing Address - Street 1:21519 HARPER AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2220
Mailing Address - Country:US
Mailing Address - Phone:586-445-3706
Mailing Address - Fax:
Practice Address - Street 1:21519 HARPER AVE STE 108
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2220
Practice Address - Country:US
Practice Address - Phone:586-445-3706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISD070545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1105010262OtherBCBS
MI4354525Medicaid
MI4354525Medicaid