Provider Demographics
NPI:1689605826
Name:LAUREL SURGERY & ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:LAUREL SURGERY & ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-369-2021
Mailing Address - Street 1:1710 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2559
Mailing Address - Country:US
Mailing Address - Phone:601-369-2021
Mailing Address - Fax:
Practice Address - Street 1:1710 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2559
Practice Address - Country:US
Practice Address - Phone:601-369-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS025261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000050710OtherBLUE CROSS BLUE SHIELD
MS01357572Medicaid
MS490000049Medicare ID - Type Unspecified