Basic Information
| Provider Information | |||||||||
| NPI: | 1982648853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143735740 | ||||||||
| FaxNumber: | 3143735757 | ||||||||
| Practice Location | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143735740 | ||||||||
| FaxNumber: | 3143735757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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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 | 207P00000X | 036094845 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00184556 | 01 | IL | RAILROAD MEDICARE | OTHER | 0360948454 | 05 | IL | MEDICAID | 0360948456 | 05 | IL | MEDICAID |