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General NPI Number Information
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NPI Number | 1821155177
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Entity Type | Organization
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Legal Business Name | GREAT LAKES GASTROENTEROLOGY CONSULTANTS, LLC
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 2702 NAVARRE AVE SUITE 106
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City | OREGON
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State | OH
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Zip | 43616-3223
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Country | US
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Telephone | 419-696-5555
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Fax | 419-696-8499
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Provider Business Mailing Address
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Address Line | 2702 NAVARRE AVE SUITE 106
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City | OREGON
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State | OH
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Zip | 43616-3223
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Country | US
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Telephone | 419-696-5555
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Fax | 419-696-8499
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUDHAKAR N. PANGULUR
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Credential | M.D.
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Telephone | 419-696-5555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State | OH
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