Provider Demographics
NPI:1164491684
Name:LAWRENCE, CHARLES G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:LAWRENCE
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 1:8485 ALGOMA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9102
Mailing Address - Country:US
Mailing Address - Phone:616-863-6220
Mailing Address - Fax:616-863-6221
Practice Address - Street 1:1200 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9704
Practice Address - Country:US
Practice Address - Phone:616-243-5707
Practice Address - Fax:616-243-1170
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4738247Medicaid
MI11281623OtherCAQH
MI4738247Medicaid