Provider Demographics
NPI:1477532786
Name:ADVANCED LAPAROSCOPIC SURGERY ASSOCIATES OF GEORGIA
Entity Type:Organization
Organization Name:ADVANCED LAPAROSCOPIC SURGERY ASSOCIATES OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIHESHA
Authorized Official - Middle Name:LONEE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-565-8753
Mailing Address - Street 1:909 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 140 BOX 132
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7247
Mailing Address - Country:US
Mailing Address - Phone:678-565-8753
Mailing Address - Fax:678-565-8902
Practice Address - Street 1:150 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 101
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7344
Practice Address - Country:US
Practice Address - Phone:678-565-8753
Practice Address - Fax:678-565-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054703208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA02BDHWVMedicare ID - Type Unspecified
GAI24397Medicare UPIN