1124083365 NPI number — DARYL M LAWRENCE-FRIEDL D.O.

Table of content: DARYL M LAWRENCE-FRIEDL D.O. (NPI 1124083365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124083365 NPI number — DARYL M LAWRENCE-FRIEDL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE-FRIEDL
Provider First Name:
DARYL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1124083365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
877 FOREST HILL AVE., SE,
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-2380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-954-0402
Provider Business Mailing Address Fax Number:
616-954-0404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
877 FOREST HILL AVE., SE,
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-2380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-954-0402
Provider Business Practice Location Address Fax Number:
616-954-0404
Provider Enumeration Date:
04/19/2006

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: 207P00000X , with the licence number:  5101010305 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 5101010305 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639382211 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DH2054 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0D12216 . This is a "BCBS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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