Basic Information
| Provider Information | |||||||||
| NPI: | 1790910917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED LAPAROSCOPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4737 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074744737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738268291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61 N MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074503255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014457070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | VOSOUGH | ||||||||
| AuthorizedOfficialFirstName: | KHASHAYAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9738268291 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA06580400 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.