MEDICARE: LASER SPINE INSTITUTE LL SOLE MBR

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1891207569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASER SPINE INSTITUTE LL SOLE MBR

Provider Business Mailing Address
First Line	:	5332 AVION PARK DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-1412
Country	:	US
Telephone Number	:	813-392-7604
Fax Number	:	484-253-1790

Provider Business Practice Location Address
First Line	:	4727 GAILLARDIA PKWY STE 140
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-1927
Country	:	US
Telephone Number	:	813-289-9613
Fax Number	:	484-253-1790

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MICHAEL PERRY
Credential	:	MD
Telephone Number	:	813-289-9613

Provider Enumeration Date	:	11/02/2017
Last Update Date	:	11/02/2017

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