1336335785 NPI number — GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C

Table of content: (NPI 1336335785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336335785 NPI number — GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336335785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7971 MOORSBRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-4075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-329-2900
Provider Business Mailing Address Fax Number:
269-329-1408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7971 MOORSBRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-329-2900
Provider Business Practice Location Address Fax Number:
269-329-1408
Provider Enumeration Date:
09/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLURU
Authorized Official First Name:
RAGHURAM
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
269-329-2900

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  RE07166 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0C90475 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103481434 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629075668 . This is a "DR ELLURU NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103481480 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1811994841 . This is a "DR HOLLEY NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103481390 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0A30093 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103481443 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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