Provider Demographics
NPI:1306027073
Name:LAWRENCE DESJARLAIS MD PC
Entity Type:Organization
Organization Name:LAWRENCE DESJARLAIS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN.OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DESJARLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-264-5603
Mailing Address - Street 1:2000 CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1752
Mailing Address - Country:US
Mailing Address - Phone:517-264-5603
Mailing Address - Fax:517-264-5708
Practice Address - Street 1:2000 CURTIS RD
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1752
Practice Address - Country:US
Practice Address - Phone:517-264-5603
Practice Address - Fax:517-264-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058635174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0704603132OtherBCBSOF MICHIGAN
MI3109892Medicaid
MIF87871Medicare UPIN