Provider Demographics
NPI:1801100250
Name:KENNETH G. LAWLOR, DO, PLLC
Entity type:Organization
Organization Name:KENNETH G. LAWLOR, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERPHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:LAWLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-717-8838
Mailing Address - Street 1:PO BOX 4343
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-4343
Mailing Address - Country:US
Mailing Address - Phone:928-717-8838
Mailing Address - Fax:928-717-8832
Practice Address - Street 1:3120 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-717-8838
Practice Address - Fax:928-717-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5487207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5487OtherAZ LIC