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1336335785

NPI Code Detail

MEDICARE: GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C

MEDICARE: GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	RE07166	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0C90475	OTHER	MI	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1629075668	OTHER	MI	DR ELLURU NPI
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1811994841	OTHER	MI	DR HOLLEY NPI
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	0A30093	OTHER	MI	BLUE CROSS/BLUE SHIELD
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336335785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C

Provider Business Mailing Address
First Line	:	7971 MOORSBRIDGE RD
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-4075
Country	:	US
Telephone Number	:	269-329-2900
Fax Number	:	269-329-1408

Provider Business Practice Location Address
First Line	:	7971 MOORSBRIDGE RD
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-4075
Country	:	US
Telephone Number	:	269-329-2900
Fax Number	:	269-329-1408

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. RAGHURAM G ELLURU
Credential	:
Telephone Number	:	269-329-2900

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	04/17/2013

Similar Medicare Providers

1811994841 — DR. SCOTT DONALD HOLLEY M.D., F.A.C.S.
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-329-2900
Practice Fax: 269-329-1408

1629075668 — DR. RAGHURAM GOP ELLURU M.D., F.A.C.S.
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-329-2900
Practice Fax: 269-329-1408

1437378932 — GREAT LAKES HAND THERAPY PC
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-321-0929
Practice Fax: 269-321-1767

1760603427 — NANCY ELLEN KROLIKOWSKI O.T.
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-321-0929
Practice Fax: 269-321-1767

1316169303 — BRYAN LEE HERDER O.T.
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-321-0929
Practice Fax: 269-321-1767

1184886111 — MICHAEL P MASKILL DPM
Practice Location Address:

7971 MOORSBRIDGE RD
PORTAGE, MI
49024-4075

Practice Phone: 269-323-2094
Practice Fax:

Directions to “GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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