Healthcare Provider Details

I. General information

NPI: 1457377673
Provider Name (Legal Business Name): LAWRENCE N EISENMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV NEUROLOGY ADULT, STE 6C
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1408
  • Fax: 314-747-8427
Mailing address:
  • Phone: 314-362-1408
  • Fax: 314-747-8427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number115434
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number115434
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number115434
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: