Provider Demographics
NPI:1164419818
Name:LI, LAWRENCE KC (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:KC
Last Name:LI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1645
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-1645
Mailing Address - Country:US
Mailing Address - Phone:309-454-1616
Mailing Address - Fax:309-454-5167
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-454-1616
Practice Address - Fax:309-454-5167
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360924582Medicaid
IL0360924582Medicaid
E86933Medicare UPIN