Provider Demographics
NPI:1851496905
Name:LAUREL EAR, NOSE, AND THROAT SURGICAL CLINIC
Entity Type:Organization
Organization Name:LAUREL EAR, NOSE, AND THROAT SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-649-8732
Mailing Address - Street 1:128 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4313
Mailing Address - Country:US
Mailing Address - Phone:601-649-8732
Mailing Address - Fax:601-649-5051
Practice Address - Street 1:128 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4313
Practice Address - Country:US
Practice Address - Phone:601-649-8732
Practice Address - Fax:601-649-5051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06389207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty