1780851428 NPI number — DR. EILEEN PATRICE LAURENCE M.D.

Table of content: DR. EILEEN PATRICE LAURENCE M.D. (NPI 1780851428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780851428 NPI number — DR. EILEEN PATRICE LAURENCE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAURENCE
Provider First Name:
EILEEN
Provider Middle Name:
PATRICE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EPSTEIN
Provider Other First Name:
EILEEN
Provider Other Middle Name:
PATRICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1780851428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26633 NORTH MIDDLETON PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNDELEIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60060-9124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-256-4123
Provider Business Mailing Address Fax Number:
224-778-5134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 CHICK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METROPOLIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62960-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-524-2176
Provider Business Practice Location Address Fax Number:
618-524-4131
Provider Enumeration Date:
05/12/2008

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: 207PE0004X , with the licence number:  036054682 , 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)





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