Healthcare Provider Details

I. General information

NPI: 1851496905
Provider Name (Legal Business Name): LAUREL EAR, NOSE, AND THROAT SURGICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 S 11TH AVE
LAUREL MS
39440-4313
US

IV. Provider business mailing address

128 S 11TH AVE
LAUREL MS
39440-4313
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-8732
  • Fax: 601-649-5051
Mailing address:
  • Phone: 601-649-8732
  • Fax: 601-649-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number06389
License Number StateMS

VIII. Authorized Official

Name: DR. MICHAEL P BROOKS
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 601-649-8732