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NPI Code Detail

MEDICARE: DR. RAGHURAM GOP ELLURU M.D., F.A.C.S.

MEDICARE: DR. RAGHURAM GOP ELLURU M.D., F.A.C.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208200000XPlastic Surgery PhysicianRE071666MI
22082S0105XSurgery of the Hand (Plastic Surgery) PhysicianRE071666MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10C90475OTHERMIBLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number : 1629075668
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RAGHURAM GOP ELLURU M.D., F.A.C.S.
Provider Business Mailing Address
First Line : 7971 MOORSBRIDGE RD
Second Line :
City : PORTAGE
State : MI
Zip : 49024-4075
Country : US
Telephone Number : 269-329-2900
Fax Number : 269-329-1408
Provider Business Practice Location Address
First Line : 7971 MOORSBRIDGE RD
Second Line :
City : PORTAGE
State : MI
Zip : 49024-4075
Country : US
Telephone Number : 269-329-2900
Fax Number : 269-329-1408
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2005
Last Update Date : 04/17/2013

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