Provider Demographics
NPI:1467851139
Name:GREAT LAKES HEALTHCARE SPECIALISTS LLC
Entity Type:Organization
Organization Name:GREAT LAKES HEALTHCARE SPECIALISTS LLC
Other - Org Name:INDIANA EAR AND SINUS INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHRIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VENTRAPRAGADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-9368
Mailing Address - Street 1:2211 MAIN ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3514
Mailing Address - Country:US
Mailing Address - Phone:219-836-9368
Mailing Address - Fax:219-836-9357
Practice Address - Street 1:2211 MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-3514
Practice Address - Country:US
Practice Address - Phone:219-836-9368
Practice Address - Fax:219-836-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty