Provider Demographics
NPI:1467568089
Name:BURCH, LAWRENCE G (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:G
Last Name:BURCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9040
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-9040
Mailing Address - Country:US
Mailing Address - Phone:618-462-0499
Mailing Address - Fax:618-462-1150
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-465-8019
Practice Address - Fax:618-463-5004
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC40718Medicare UPIN