Provider Demographics
NPI:1568874832
Name:LASER SPINE SURGERY CENTER OF ST. LOUIS, LLC
Entity Type:Organization
Organization Name:LASER SPINE SURGERY CENTER OF ST. LOUIS, LLC
Other - Org Name:LASER SPINE SURGERY CENTER OF MISSOURI, LLC
Other - Org Type:Former Legal Business Name
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 DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1412
Mailing Address - Country:US
Mailing Address - Phone:813-682-2944
Mailing Address - Fax:484-253-1790
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6835
Practice Address - Country:US
Practice Address - Phone:314-930-2693
Practice Address - Fax:484-253-1790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LSI HOLDCO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-21
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical