Provider Demographics
NPI:1225100548
Name:LAWLESS, ANDREA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:LAWLESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7431 E STATE ST
Mailing Address - Street 2:#132
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2678
Mailing Address - Country:US
Mailing Address - Phone:815-986-2610
Mailing Address - Fax:815-986-6287
Practice Address - Street 1:7479 WALTON ST
Practice Address - Street 2:SUITE 4
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4613
Practice Address - Country:US
Practice Address - Phone:815-986-2610
Practice Address - Fax:815-986-6287
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-064202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42198Medicare UPIN