Basic Information
| Provider Information | |||||||||
| NPI: | 1629208392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORUKANTI | ||||||||
| FirstName: | PAVAN | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 W FAIR AVE | ||||||||
| Address2: | STE 211 | ||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498555406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253912 | ||||||||
| FaxNumber: | 9062257538 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | HARVEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498559101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179748055 | ||||||||
| FaxNumber: | 5174323145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301094183 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629208392 | 05 | MI | MEDICAID |