1780874784 NPI number — ADVANCED LAPAROSCOPIC SURGERY OF FORT MYERS LLC

Table of content: (NPI 1780874784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780874784 NPI number — ADVANCED LAPAROSCOPIC SURGERY OF FORT MYERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED LAPAROSCOPIC SURGERY OF FORT MYERS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780874784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 WILLIAMS AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LEHIGH ACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33972-7954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-209-7543
Provider Business Mailing Address Fax Number:
866-586-6004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 WILLIAMS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33972-7954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-303-5273
Provider Business Practice Location Address Fax Number:
866-586-6004
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCGRAW
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-209-7543

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME96681 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 178150564104 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3954998 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 18294 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2822788 . This is a "UNITED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9344077 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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