MEDICARE: GENERAL AND ADVANCED LAPAROSCOPIC SURGERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	02003334A	IN

General Provider Information

NPI Number	:	1588811137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERAL AND ADVANCED LAPAROSCOPIC SURGERY, LLC

Provider Business Mailing Address
First Line	:	3520 GUION RD
Second Line	:	SUITE 103
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1692
Country	:	US
Telephone Number	:	317-682-2038
Fax Number	:	317-920-7482

Provider Business Practice Location Address
First Line	:	3520 GUION RD
Second Line	:	SUITE 103
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1692
Country	:	US
Telephone Number	:	317-682-2038
Fax Number	:	317-920-7482

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. DOUGLAS A REX
Credential	:	D.O.
Telephone Number	:	317-682-2038

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	08/26/2008

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