Healthcare Provider Details

I. General information

NPI: 1467851139
Provider Name (Legal Business Name): GREAT LAKES HEALTHCARE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAIN ST STE 1A
HIGHLAND IN
46322-3514
US

IV. Provider business mailing address

2211 MAIN ST STE 1A
HIGHLAND IN
46322-3514
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-9368
  • Fax: 219-836-9357
Mailing address:
  • Phone: 219-836-9368
  • Fax: 219-836-9357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SHRIDHAR VENTRAPRAGADA
Title or Position: OWNER
Credential: M.D.
Phone: 219-836-9368