Healthcare Provider Details

I. General information

NPI: 1164419818
Provider Name (Legal Business Name): LAWRENCE K.C. LI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD SUITE 250
NORMAL IL
61761-6286
US

IV. Provider business mailing address

PO BOX 1645
BLOOMINGTON IL
61702-1645
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1616
  • Fax: 309-454-5167
Mailing address:
  • Phone: 309-454-1616
  • Fax: 309-454-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: