=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336335785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2007
-----------------------------------------------------
Last Update Date | 04/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7971 MOORSBRIDGE RD
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-4075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-329-2900
-----------------------------------------------------
Fax | 269-329-1408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7971 MOORSBRIDGE RD
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-4075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-329-2900
-----------------------------------------------------
Fax | 269-329-1408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. RAGHURAM G ELLURU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-329-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | RE07166
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------