1063403848 NPI number — DR. BRETT D LAWLOR MD

Table of content: DR. BRETT D LAWLOR MD (NPI 1063403848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063403848 NPI number — DR. BRETT D LAWLOR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWLOR
Provider First Name:
BRETT
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063403848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 JACKSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57702-4335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-721-7246
Provider Business Mailing Address Fax Number:
605-341-4501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 JACKSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57702-4335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-721-7246
Provider Business Practice Location Address Fax Number:
605-341-4501
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  4193 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: 4193 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31783 . This is a "SANDFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4193 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 115322600 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 41194500700 . This is a "NEBRASKA MEDICAID" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 1063403848 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0006333 . This is a "WELLMARK BCBS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 31783 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 13327600 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 2300560 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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