Healthcare Provider Details

I. General information

NPI: 1053644872
Provider Name (Legal Business Name): LAWRENCE G EVANS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE SUITE 400
FENTON MO
63026-2395
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-4884
  • Fax: 314-821-4885
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31680
License Number StateMO

VIII. Authorized Official

Name: LAWRENCE G EVANS
Title or Position: OWNER
Credential: MD
Phone: 314-821-4884