Provider Demographics
NPI:1336170257
Name:ADVANCED VIDEOSCOPIC SURGERY OF BATON ROUGE
Entity Type:Organization
Organization Name:ADVANCED VIDEOSCOPIC SURGERY OF BATON ROUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DRAKE
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:BELLANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-819-0983
Mailing Address - Street 1:9094 PERKINS ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:225-819-0983
Mailing Address - Fax:225-819-0986
Practice Address - Street 1:9094 PERKINS ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-819-0983
Practice Address - Fax:225-819-0986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11666R208600000X
AL00017405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1697486Medicaid
LA1697486Medicaid
5Y431Medicare ID - Type Unspecified