Healthcare Provider Details

I. General information

NPI: 1336119171
Provider Name (Legal Business Name): LAWRENCE MERION LAVINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S VIRGINIA ST
CRYSTAL LAKE IL
60014-5826
US

IV. Provider business mailing address

1 S VIRGINIA ST
CRYSTAL LAKE IL
60014-5826
US

V. Phone/Fax

Practice location:
  • Phone: 260-414-4990
  • Fax:
Mailing address:
  • Phone: 260-414-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036049364
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036-049364
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: