=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215963616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED LAPAROSCOPIC ASSOCIATES OF MS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2006
-----------------------------------------------------
Last Update Date | 11/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1018 SIXTH AVE
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-799-3011
-----------------------------------------------------
Fax | 601-799-5417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1018 SIXTH AVE
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-799-3011
-----------------------------------------------------
Fax | 601-799-5417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAPAROSCOPIC AND GENERAL SURGEON
-----------------------------------------------------
Name | ALFRED BERNARD JOHNSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-799-3011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 19035
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------