Provider Demographics
NPI:1194214510
Name:SPECIALTY SURGERY & LASER CENTER
Entity Type:Organization
Organization Name:SPECIALTY SURGERY & LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHIPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-286-6068
Mailing Address - Street 1:306 BRADLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-7047
Mailing Address - Country:US
Mailing Address - Phone:662-286-6068
Mailing Address - Fax:662-286-0188
Practice Address - Street 1:306 BRADLEY RD STE A
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-7047
Practice Address - Country:US
Practice Address - Phone:662-286-6068
Practice Address - Fax:662-286-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty