Provider Demographics
NPI:1568470227
Name:LAPAROSCOPY BARIATRICS & SURGERY PA
Entity Type:Organization
Organization Name:LAPAROSCOPY BARIATRICS & SURGERY PA
Other - Org Name:ULTIMATE BARIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PLENERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-916-4699
Mailing Address - Street 1:2501 PARKVIEW DR
Mailing Address - Street 2:SUITE 560
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5824
Mailing Address - Country:US
Mailing Address - Phone:817-850-1100
Mailing Address - Fax:817-850-1104
Practice Address - Street 1:2501 PARKVIEW DR
Practice Address - Street 2:SUITE 560
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5824
Practice Address - Country:US
Practice Address - Phone:817-850-1100
Practice Address - Fax:817-870-2553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7229174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00617XMedicare PIN