Healthcare Provider Details

I. General information

NPI: 1780851428
Provider Name (Legal Business Name): EILEEN PATRICE LAURENCE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EILEEN PATRICE EPSTEIN

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CHICK ST
METROPOLIS IL
62960-2467
US

IV. Provider business mailing address

26633 NORTH MIDDLETON PARKWAY
MUNDELEIN IL
60060-9124
US

V. Phone/Fax

Practice location:
  • Phone: 618-524-2176
  • Fax: 618-524-4131
Mailing address:
  • Phone: 847-256-4123
  • Fax: 224-778-5134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036054682
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: