Healthcare Provider Details

I. General information

NPI: 1720538341
Provider Name (Legal Business Name): SOUTHWEST MICHIGAN PLASTIC AND HAND SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7971 MOORSBRIDGE RD
PORTAGE MI
49024-4075
US

IV. Provider business mailing address

7971 MOORSBRIDGE RD
PORTAGE MI
49024-4075
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-2900
  • Fax: 269-329-1408
Mailing address:
  • Phone: 269-329-2900
  • Fax: 269-329-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RAGHU ELLURU
Title or Position: MD
Credential:
Phone: 269-273-9789