Healthcare Provider Details

I. General information

NPI: 1871757708
Provider Name (Legal Business Name): SURESH POTLURI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 GULL RD
KALAMAZOO MI
49048-1609
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 269-633-2510
  • Fax: 269-633-2511
Mailing address:
  • Phone: 574-647-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301093703
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01086616A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01086616A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301093703
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: