1912265117 NPI number — VALERIE ELIZABETH LAWRENCE M.D.

Table of content: VALERIE ELIZABETH LAWRENCE M.D. (NPI 1912265117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912265117 NPI number — VALERIE ELIZABETH LAWRENCE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
VALERIE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
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:
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:
1912265117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W PARK ST
Provider Second Line Business Mailing Address:
BWPC
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-383-6941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2512 HURST DR
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-258-5900
Provider Business Practice Location Address Fax Number:
217-258-3686
Provider Enumeration Date:
04/25/2012

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: 208000000X , with the licence number:  036138867 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 63210 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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