1669513982 NPI number — LAWRENCE A SHORT DPM LTD

Table of content: (NPI 1669513982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669513982 NPI number — LAWRENCE A SHORT DPM LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE A SHORT DPM LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UNIVERSITY FOOT ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1669513982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 WAUKEGAN RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAKE BLUFF
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60044-1662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-295-9300
Provider Business Mailing Address Fax Number:
847-295-9607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 WAUKEGAN RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAKE BLUFF
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60044-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-295-9300
Provider Business Practice Location Address Fax Number:
847-295-9607
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHORT
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-295-9300

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  016003095 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000102466006 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 60021233 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com