MEDICARE: LAWRENCE NELSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36089481	IL
2	2086S0127X	Trauma Surgery Physician	036-089481	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00470671	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4673170001	OTHER	IL	DMERC

General Provider Information

NPI Number	:	1427035534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE NELSON DO

Provider Business Mailing Address
First Line	:	8103 BURDEN RD
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-8208
Country	:	US
Telephone Number	:	815-713-2600
Fax Number	:	815-654-8020

Provider Business Practice Location Address
First Line	:	8103 BURDEN RD
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-8208
Country	:	US
Telephone Number	:	815-713-2600
Fax Number	:	815-654-8020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	06/13/2008

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