Provider Demographics
NPI:1083729248
Name:LASER SPINE SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:LASER SPINE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-289-9613
Mailing Address - Street 1:5332 AVION PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-682-2944
Mailing Address - Fax:484-253-1790
Practice Address - Street 1:5332 AVION PARK DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-682-2944
Practice Address - Fax:484-253-1790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LSI HOLDCO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1250261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical