Healthcare Provider Details

I. General information

NPI: 1508022104
Provider Name (Legal Business Name): LAWRENCE BLUEFORD YEAGER IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2008
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

440 N MCCLURG CT #313
CHICAGO IL
60611-4370
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-4673
  • Fax:
Mailing address:
  • Phone: 312-245-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125050816
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: