Provider Demographics
NPI:1407151772
Name:ADVANCE LAPAROSCOPIC SURGERY INSTITUTE, INC.
Entity Type:Organization
Organization Name:ADVANCE LAPAROSCOPIC SURGERY INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-333-3584
Mailing Address - Street 1:PO BOX 62600
Mailing Address - Street 2:DEPT. 1867
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70162-2600
Mailing Address - Country:US
Mailing Address - Phone:678-333-3584
Mailing Address - Fax:678-668-7965
Practice Address - Street 1:3890 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1284
Practice Address - Country:US
Practice Address - Phone:678-333-3584
Practice Address - Fax:678-668-7965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055763208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA402816379AMedicaid
GA08255G043Medicare PIN