Provider Demographics
NPI:1831409838
Name:ADVANCED LAPAROSCOPIC SURGICAL, LLC
Entity type:Organization
Organization Name:ADVANCED LAPAROSCOPIC SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-671-9556
Mailing Address - Street 1:PO BOX 102294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2294
Mailing Address - Country:US
Mailing Address - Phone:404-294-0257
Mailing Address - Fax:678-252-6675
Practice Address - Street 1:5910 HILLANDALE DR STE 209
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1880
Practice Address - Country:US
Practice Address - Phone:404-294-0257
Practice Address - Fax:678-252-6675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-12
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051545208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty