=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447206537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDRIA NEUROSURGICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 08/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3704 NORTH BLVD SUITE C
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-443-4576
-----------------------------------------------------
Fax | 318-449-5579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3704 NORTH BLVD SUITE C
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-3606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-443-4576
-----------------------------------------------------
Fax | 318-449-5579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL LAWRENCE DRERUP
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 318-443-4576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------