Basic Information
| Provider Information | |||||||||
| NPI: | 1427035534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8103 BURDEN RD | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611158208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132600 | ||||||||
| FaxNumber: | 8156548020 | ||||||||
| Practice Location | |||||||||
| Address1: | 8103 BURDEN RD | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611158208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132600 | ||||||||
| FaxNumber: | 8156548020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36089481 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 2086S0127X | 036-089481 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4673170001 | 01 | IL | DMERC | OTHER | P00470671 | 01 | IL | RAILROAD MEDICARE | OTHER |