MEDICARE: DR. PAVAN KUMAR GORUKANTI M.D.

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	207R00000X	Internal Medicine Physician	4301094183	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629208392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAVAN KUMAR GORUKANTI M.D.

Provider Business Mailing Address
First Line	:	1414 W FAIR AVE
Second Line	:	STE 211
City	:	MARQUETTE
State	:	MI
Zip	:	49855-5406
Country	:	US
Telephone Number	:	906-225-3912
Fax Number	:	906-225-7538

Provider Business Practice Location Address
First Line	:	170 BAYOU ST
Second Line	:
City	:	HARVEY
State	:	MI
Zip	:	49855-9101
Country	:	US
Telephone Number	:	517-974-8055
Fax Number	:	517-432-3145

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2009
Last Update Date	:	05/30/2017

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