Basic Information
| Provider Information | |||||||||
| NPI: | 1407945926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED LAPAROSCOPIC BARIATRIC SURGERY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 PINE VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434025201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193523067 | ||||||||
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| Practice Location | |||||||||
| Address1: | 960 W WOOSTER ST | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193737699 | ||||||||
| FaxNumber: | 4193547430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LANE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4193737699 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 35.086946 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 2510018 | 05 | OH | MEDICAID |