MEDICARE: LAWRENCE A DETWILER M.D.

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	207R00000X	Internal Medicine Physician	35-04-2991	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	110146704	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000030812	OTHER	OH	ANTHEM BCBS
2	393375	OTHER	OH	WELLCARE OF OH
3	P42991	OTHER	OH	SUMMACARE HEALTH PLAN
4	341847368031	OTHER	OH	CARESOURCE
6	000000030812	OTHER	OH	UNICARE
7	4009105	OTHER	OH	AETNA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	57106	OTHER	OH	TRICARE
10	105347	OTHER	OH	KAISER

General Provider Information

NPI Number	:	1750373650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE A DETWILER M.D.

Provider Business Mailing Address
First Line	:	7575 NORTHCLIFF AVE
Second Line	:	SUITE 102
City	:	BROOKLYN
State	:	OH
Zip	:	44144-3267
Country	:	US
Telephone Number	:	216-398-8196
Fax Number	:	216-398-8192

Provider Business Practice Location Address
First Line	:	7575 NORTHCLIFF AVE
Second Line	:	SUITE 102
City	:	BROOKLYN
State	:	OH
Zip	:	44144-3267
Country	:	US
Telephone Number	:	216-398-8196
Fax Number	:	216-398-8192

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

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	05/30/2008

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Directions to “ LAWRENCE A DETWILER M.D.” Practice Location

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