Provider Demographics
NPI:1447446992
Name:CENTER FOR ADVANCED LAPAROSCOPIC AND BARIATRIC SURGERY, LLC
Entity type:Organization
Organization Name:CENTER FOR ADVANCED LAPAROSCOPIC AND BARIATRIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-330-9962
Mailing Address - Street 1:506 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2316
Mailing Address - Country:US
Mailing Address - Phone:812-330-9962
Mailing Address - Fax:812-330-9967
Practice Address - Street 1:506 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2316
Practice Address - Country:US
Practice Address - Phone:812-961-0370
Practice Address - Fax:812-330-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN04046774A261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM300017337Medicare UPIN