Provider Demographics
NPI:1598723504
Name:LAWRENCE P JENNINGS M D M S C
Entity Type:Organization
Organization Name:LAWRENCE P JENNINGS M D M S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-262-5113
Mailing Address - Street 1:1430 COLLEGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-2649
Mailing Address - Country:US
Mailing Address - Phone:618-262-5113
Mailing Address - Fax:618-263-3195
Practice Address - Street 1:1430 COLLEGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2649
Practice Address - Country:US
Practice Address - Phone:618-262-5113
Practice Address - Fax:618-263-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09320171OtherBLUE CROSS BLUE SHIELD
ILP00169369OtherMEDICARE RAILROAD
IL09320171OtherBLUE CROSS BLUE SHIELD
IL148950Medicare ID - Type Unspecified
IL=========001Medicaid
IL09320171OtherBLUE CROSS BLUE SHIELD