MEDICARE: SOUTHERN LASER SPINE GROUP 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	207XS0117X	Orthopaedic Surgery of the Spine Physician

General Provider Information

NPI Number	:	1558895730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN LASER SPINE GROUP LLC

Provider Business Mailing Address
First Line	:	1216 SE 1ST AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-1802
Country	:	US
Telephone Number	:	954-255-8406
Fax Number	:

Provider Business Practice Location Address
First Line	:	1216 SE 1ST AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-1802
Country	:	US
Telephone Number	:	954-255-8406
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LAWRENCE ALEXANDER
Credential	:	MD
Telephone Number	:	954-255-8406

Provider Enumeration Date	:	04/14/2017
Last Update Date	:	04/14/2017

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