Provider Demographics
NPI:1013188424
Name:L ROYCE LARSEN MD LLC
Entity Type:Organization
Organization Name:L ROYCE LARSEN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:L ROYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-446-5900
Mailing Address - Street 1:800 N LOGAN AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3741
Mailing Address - Country:US
Mailing Address - Phone:217-446-5900
Mailing Address - Fax:217-446-3810
Practice Address - Street 1:800 N LOGAN AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3741
Practice Address - Country:US
Practice Address - Phone:217-446-5900
Practice Address - Fax:217-446-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001Medicare NSC
C48310Medicare UPIN