Basic Information
Provider Information
NPI: 1821155177
EntityType: 2
ReplacementNPI:  
OrganizationName: GREAT LAKES GASTROENTEROLOGY CONSULTANTS, LLC
LastName:  
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Mailing Information
Address1: 2702 NAVARRE AVE
Address2: SUITE 106
City: OREGON
State: OH
PostalCode: 436163223
CountryCode: US
TelephoneNumber: 4196965555
FaxNumber: 4196968499
Practice Location
Address1: 2702 NAVARRE AVE
Address2: SUITE 106
City: OREGON
State: OH
PostalCode: 436163223
CountryCode: US
TelephoneNumber: 4196965555
FaxNumber: 4196968499
Other Information
ProviderEnumerationDate: 01/03/2007
LastUpdateDate: 05/09/2008
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: PANGULUR
AuthorizedOfficialFirstName: SUDHAKAR
AuthorizedOfficialMiddleName: N.
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 4196965555
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100X OHY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology

ID Information
IDTypeStateIssuerDescription
228626205OH MEDICAID


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