Provider Demographics
NPI:1336354356
Name:LAWRENCE VIDAVER MD
Entity Type:Organization
Organization Name:LAWRENCE VIDAVER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-298-8223
Mailing Address - Street 1:2506 LARRYVALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3206
Mailing Address - Country:US
Mailing Address - Phone:410-764-1116
Mailing Address - Fax:410-298-8225
Practice Address - Street 1:1411 MADISON PARK DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5613
Practice Address - Country:US
Practice Address - Phone:410-761-1037
Practice Address - Fax:410-298-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-12
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD025559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB69824Medicare UPIN
MD8634Medicare PIN