Basic Information
Provider Information | |||||||||
NPI: | 1821155177 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREAT LAKES GASTROENTEROLOGY CONSULTANTS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PANGULUR | ||||||||
AuthorizedOfficialFirstName: | SUDHAKAR | ||||||||
AuthorizedOfficialMiddleName: | N. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4196965555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X |   | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 2286262 | 05 | OH |   | MEDICAID |