Organization
GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
Active
Other names
GREAT LAKES PLASTIC AND HAND SURGERY
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RAGHURAM G ELLURU (MANAGING PARTNER)
(269) 329-2900
Entity
Organization
Contact information
Practice address
7971 MOORSBRIDGE RD, PORTAGE, MI 49024-4075
(269) 329-2900
(269) 329-1408
Mailing address
7971 MOORSBRIDGE RD, PORTAGE, MI 49024-4075
(269) 329-2900
(269) 329-1408
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
RE07166
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0A30093
BLUE CROSS/BLUE SHIELD
MI
01
—
0C90475
BLUE CROSS/BLUE SHIELD
MI
05
—
103481390
—
MI
05
—
103481434
—
MI
05
—
103481443
—
MI
05
—
103481480
—
MI
01
—
1629075668
DR ELLURU NPI
MI
01
—
1811994841
DR HOLLEY NPI
MI
Enumeration date
09/19/2007
Last updated
04/17/2013
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