MEDICARE: GRAND LAKE SLEEP CENTER

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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

General Provider Information

NPI Number	:	1578654950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND LAKE SLEEP CENTER

Provider Business Mailing Address
First Line	:	1040 HAGER ST
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2421
Country	:	US
Telephone Number	:	419-394-9992
Fax Number	:	419-394-9629

Provider Business Practice Location Address
First Line	:	1040 HAGER ST
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2421
Country	:	US
Telephone Number	:	419-394-9992
Fax Number	:	419-394-9629

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SARAT BABU KUCHIPUDI
Credential	:	M.D.
Telephone Number	:	419-394-9992

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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Directions to “GRAND LAKE SLEEP CENTER ” Practice Location

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