1407802697 NPI number — WILLIAM L LAURY SR. M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407802697 NPI number — WILLIAM L LAURY SR. M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LAURY

Provider First Name:

WILLIAM

Provider Middle Name:

L

Provider Name Prefix Text:

Provider Name Suffix Text:

SR.

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1407802697

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

10/18/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

175 W COHAWKIN RD STE C

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CLARKSBORO

Provider Business Mailing Address State Name:

NJ

Provider Business Mailing Address Postal Code:

08020-1145

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

856-423-7700

Provider Business Mailing Address Fax Number:

856-423-0823

Provider First Line Business Practice Location Address:

834 E UPSAL ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PHILADELPHIA

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

19119-1541

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

215-924-4440

Provider Business Practice Location Address Fax Number:

215-927-4777

Provider Enumeration Date:

05/26/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  MD016761E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0064824003 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0054066000 . This is a "IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 7104021 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 37462 . This is a "HEALTH PARTNERS PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: P526589 . This is a "OXFORD HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 37461 . This is a "HEALTH PARTNERS PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: P00079200 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0006482400004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1078975 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2166 . This is a "BRAVO ELDER HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".