Provider Demographics
NPI:1053440222
Name:TIERNEY, LAWRENCE STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:STEPHEN
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 1ST CAPITOL DR STE 201
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2882
Practice Address - Country:US
Practice Address - Phone:636-669-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J21207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000095326Medicare ID - Type Unspecified
MOF59343Medicare UPIN