Provider Demographics
NPI:1336335785
Name:GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
Entity Type:Organization
Organization Name:GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
Other - Org Name:GREAT LAKES PLASTIC AND HAND SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAGHURAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:ELLURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-329-2900
Mailing Address - Street 1:7971 MOORSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4075
Mailing Address - Country:US
Mailing Address - Phone:269-329-2900
Mailing Address - Fax:269-329-1408
Practice Address - Street 1:7971 MOORSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4075
Practice Address - Country:US
Practice Address - Phone:269-329-2900
Practice Address - Fax:269-329-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRE07166208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C90475OtherBLUE CROSS/BLUE SHIELD
MI103481434Medicaid
MI1629075668OtherDR ELLURU NPI
MI103481480Medicaid
MI1811994841OtherDR HOLLEY NPI
MI103481390Medicaid
MI0A30093OtherBLUE CROSS/BLUE SHIELD
MI103481443Medicaid
MI103481434Medicaid