Provider Demographics
NPI:1780874784
Name:ADVANCED LAPAROSCOPIC SURGERY OF FORT MYERS LLC
Entity type:Organization
Organization Name:ADVANCED LAPAROSCOPIC SURGERY OF FORT MYERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MCGRAW
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:239-209-7543
Mailing Address - Street 1:615 WILLIAMS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-7954
Mailing Address - Country:US
Mailing Address - Phone:239-209-7543
Mailing Address - Fax:866-586-6004
Practice Address - Street 1:615 WILLIAMS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-7954
Practice Address - Country:US
Practice Address - Phone:239-303-5273
Practice Address - Fax:866-586-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96681208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL178150564104OtherHUMANA
FL3954998OtherCIGNA
FL18294OtherBLUE CROSS BLUE SHIELD
FL2822788OtherUNITED
FL9344077OtherAETNA
FL9344077OtherAETNA
FL2822788OtherUNITED