Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 079624 | MI |
NPI | 1164454948 |
---|---|
Provider Name | Dr. Vipul Kella |
First Address | Royal Oak, MI 48067-3271 |
Second Address | Wyandotte, MI 48192-4668 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I41089 | (02) | |
VK079624 | BLUE SHIELD (01) | MI |