Provider Demographics
NPI:1821155177
Name:GREAT LAKES GASTROENTEROLOGY CONSULTANTS, LLC
Entity Type:Organization
Organization Name:GREAT LAKES GASTROENTEROLOGY CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:N
Authorized Official - Last Name:PANGULUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-696-5555
Mailing Address - Street 1:2702 NAVARRE AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3223
Mailing Address - Country:US
Mailing Address - Phone:419-696-5555
Mailing Address - Fax:419-696-8499
Practice Address - Street 1:2702 NAVARRE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3223
Practice Address - Country:US
Practice Address - Phone:419-696-5555
Practice Address - Fax:419-696-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2286262Medicaid
OH2286262Medicaid