MEDICARE: DR. LAWRENCE WAYNE SHIVERTAKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	202C00000X	Independent Medical Examiner Physician	ME60157	FL

General Provider Information

NPI Number	:	1194963454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE WAYNE SHIVERTAKER MD

Provider Business Mailing Address
First Line	:	2486 SHALIMAR LN
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-6123
Country	:	US
Telephone Number	:	904-269-5274
Fax Number	:

Provider Business Practice Location Address
First Line	:	2486 SHALIMAR LN
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-6123
Country	:	US
Telephone Number	:	904-269-5274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2009
Last Update Date	:	01/25/2009

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