Provider Demographics
NPI:1295720993
Name:BIRD, LAURA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BIRD
Suffix:
Gender:F
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 959203
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9203
Mailing Address - Country:US
Mailing Address - Phone:618-433-7901
Mailing Address - Fax:618-433-7940
Practice Address - Street 1:2 MEMORIAL DR STE 220
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-433-7901
Practice Address - Fax:618-433-7940
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096129Medicaid
IL036096129Medicaid
IL596390Medicare ID - Type Unspecified