Basic Information
| Provider Information | |||||||||
| NPI: | 1508022104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YEAGER | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | BLUEFORD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 N MCCLURG CT | ||||||||
| Address2: | #313 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122450653 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 E SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124724673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2008 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 125050816 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 125050816 | 01 | IL | ILLINOIS STATE LISCENCE NUMBER | OTHER |