1770669210 NPI number — KENNETH R LAWRENCE DPM PC

Table of content: (NPI 1770669210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770669210 NPI number — KENNETH R LAWRENCE DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH R LAWRENCE DPM PC
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:
1770669210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24300 ORCHARD LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48336-1935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30335 W 13 MILE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-476-1616
Provider Business Practice Location Address Fax Number:
248-476-6683
Provider Enumeration Date:
10/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
248-476-1616

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CA5369 . This is a "MEDICARE B RAILROAD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 480009796 . This is a "MEDICARE RR PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".