Provider Demographics
NPI:1063850329
Name:MICHIGAN INSTITUTE FOR LAPAROSCOPIC SURGERY PC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE FOR LAPAROSCOPIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-255-4380
Mailing Address - Street 1:5839 W MAPLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2278
Mailing Address - Country:US
Mailing Address - Phone:248-255-4380
Mailing Address - Fax:248-847-3786
Practice Address - Street 1:5839 W MAPLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-255-4380
Practice Address - Fax:248-255-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6807Medicare PIN