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General NPI Number Information
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NPI Number | 1699823450
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Entity Type | Organization
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Legal Business Name | ADVANCED SOUTHERN SURGICAL
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 05/25/2011
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Provider Practice Location Address
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Address Line | 604 N ACADIA RD SUITE 406
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City | THIBODAUX
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State | LA
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Zip | 70301-4847
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Country | US
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Telephone | 985-446-2524
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Fax | 985-447-2329
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Provider Business Mailing Address
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Address Line | 604 N ACADIA ROAD SUITE 406
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City | THIBODAUX
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State | LA
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Zip | 70301
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Country | US
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Telephone | 985-446-2524
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JOHNNY PEREZ
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Credential | M.D.
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Telephone | 985-446-2524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 15745R
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License Number State | LA
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