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Organization Active NPI

Great Lakes Plastic Reconstructive & Hand Surgery P C

Doing business as Great Lakes Plastic and Hand Surgery

  • Plastic Surgery Physician
  • Portage, MI
National Provider Identifier
1336335785
Registry record updated Apr 17, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Plastic Surgery PhysicianTaxonomy code 208200000X
License
RE07166 Issued in MI
Legal business name
GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C
Doing business as
Great Lakes Plastic and Hand Surgery
Practice address
7971 Moorsbridge Rd
Portage, MI 49024-4075
Phone
(269) 329-2900
Fax
(269) 329-1408
NPI assigned
Sep 19, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 17, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Raghuram G Elluru
Title
Managing Partner
Phone
(269) 329-2900

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Plastic Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208200000X RE07166 MI Primary

Addresses

Primary practice location

7971 Moorsbridge Rd
Portage, MI 49024-4075

Mailing address

7971 Moorsbridge Rd
Portage, MI 49024-4075
Phone (269) 329-2900

Other identifiers 8

IdentifierTypeStateIssuer
0C90475OtherMIBLUE CROSS/BLUE SHIELD
103481434MedicaidMI
1629075668OtherMIDR ELLURU NPI
103481480MedicaidMI
1811994841OtherMIDR HOLLEY NPI
103481390MedicaidMI
0A30093OtherMIBLUE CROSS/BLUE SHIELD
103481443MedicaidMI

Other names 1

  • GREAT LAKES PLASTIC AND HAND SURGERY Doing business as

National Provider Directory

National Provider Directory

Locations

3600 Capital Ave SW
Ste 102
Battle Creek, MI 49015
Phone (269) 979-0900

7971 Moorsbridge Rd
Portage, MI 49024
Phone (269) 321-0929

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1190160000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1366156800000",
    "number": "1336335785",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7971 MOORSBRIDGE RD",
            "city": "PORTAGE",
            "state": "MI",
            "postal_code": "490244075",
            "telephone_number": "269-329-2900",
            "fax_number": "269-329-1408"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7971 MOORSBRIDGE RD",
            "city": "PORTAGE",
            "state": "MI",
            "postal_code": "490244075",
            "telephone_number": "269-329-2900",
            "fax_number": "269-329-1408"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES PLASTIC RECONSTRUCTIVE & HAND SURGERY P C",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-19",
        "last_updated": "2013-04-17",
        "status": "A",
        "authorized_official_last_name": "ELLURU",
        "authorized_official_first_name": "RAGHURAM",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "269-329-2900",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "208200000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Plastic Surgery",
            "state": "MI",
            "license": "RE07166",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "0C90475",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103481434",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DR ELLURU NPI",
            "identifier": "1629075668",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103481480",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DR HOLLEY NPI",
            "identifier": "1811994841",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103481390",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "0A30093",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103481443",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "GREAT LAKES PLASTIC AND HAND SURGERY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portage, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.