1598723504 NPI number — LAWRENCE P JENNINGS M D M S C

Table of content: (NPI 1598723504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598723504 NPI number — LAWRENCE P JENNINGS M D M S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE P JENNINGS M D M S C
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:
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:
1598723504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1430 COLLEGE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MOUNT CARMEL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62863-2649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-262-5113
Provider Business Mailing Address Fax Number:
618-263-3195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1430 COLLEGE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOUNT CARMEL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62863-2649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-262-5113
Provider Business Practice Location Address Fax Number:
618-263-3195
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JENNINGS
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-262-5113

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036063272 , 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: 09320171 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00169369 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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