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General NPI Number Information
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NPI Number | 1467851139
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Entity Type | Organization
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Legal Business Name | GREAT LAKES HEALTHCARE SPECIALISTS LLC
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 01/20/2022
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Provider Practice Location Address
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Address Line | 2211 MAIN ST STE 1A
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City | HIGHLAND
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State | IN
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Zip | 46322-3514
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Country | US
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Telephone | 219-836-9368
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Fax | 219-836-9357
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Provider Business Mailing Address
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Address Line | 2211 MAIN ST STE 1A
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City | HIGHLAND
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State | IN
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Zip | 46322-3514
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Country | US
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Telephone | 219-836-9368
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Fax | 219-836-9357
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Authorized Official
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Title or Position | OWNER
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Name | MR. SHRIDHAR VENTRAPRAGADA
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Credential | M.D.
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Telephone | 219-836-9368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number |
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License Number State |
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