MEDICARE: MR. MARCELLUS R LAWRENCE MD

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	207L00000X	Anesthesiology Physician	MDRJ33	MO

General Provider Information

NPI Number	:	1588654651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARCELLUS R LAWRENCE MD

Provider Business Mailing Address
First Line	:	12303 DE PAUL DR
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2512
Country	:	US
Telephone Number	:	314-344-7049
Fax Number	:	314-344-7073

Provider Business Practice Location Address
First Line	:	12303 DE PAUL DR
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2512
Country	:	US
Telephone Number	:	314-344-7049
Fax Number	:	314-344-7073

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

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/08/2007

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