1629208392 NPI number — DR. PAVAN KUMAR GORUKANTI M.D.

Table of content: DR. PAVAN KUMAR GORUKANTI M.D. (NPI 1629208392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629208392 NPI number — DR. PAVAN KUMAR GORUKANTI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORUKANTI
Provider First Name:
PAVAN
Provider Middle Name:
KUMAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1629208392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1414 W FAIR AVE
Provider Second Line Business Mailing Address:
STE 211
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-5406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-225-3912
Provider Business Mailing Address Fax Number:
906-225-7538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 BAYOU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-9101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-974-8055
Provider Business Practice Location Address Fax Number:
517-432-3145
Provider Enumeration Date:
07/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301094183 , 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: 1629208392 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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