Provider Demographics
NPI:1356333405
Name:THRUSH, LAWRENCE BLAIR JR (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:BLAIR
Last Name:THRUSH
Suffix:JR
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 1:3411A NOYES AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-344-2459
Mailing Address - Fax:304-345-1336
Practice Address - Street 1:3411A NOYES AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-344-2459
Practice Address - Fax:304-345-1336
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11974207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000113916OtherBCBS
WV4252011OtherAETNA
WV0070499000Medicaid
WV000113916OtherBCBS
A71625Medicare UPIN