Provider Demographics
NPI:1083615751
Name:LEVINE, LAWRENCE A (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:LEVINE
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 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-7505
Practice Address - Fax:859-301-2022
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33387207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0968994Medicaid
KY64938483Medicaid
IN200965380Medicaid
B77403Medicare UPIN
KY930109675Medicare PIN
KY64938483Medicaid
IN200965380Medicaid
OH0968994Medicaid