MEDICARE: LAWRENCE GLENNON EVANS JR. M.D.

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	207X00000X	Orthopaedic Surgery Physician	31680	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	200015590	OTHER	MO	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0900150	OTHER	MO	UNITED HEALTHCARE
2	21931	OTHER	MO	BLUE CROSS/BLUE SHIELD
3	49982	OTHER	MO	GROUP HEALTH PLAN GHP
4	009102	OTHER	MO	EXCLUSIVE CHOICE
5	100636	OTHER	MO	HEALTHLINK

General Provider Information

NPI Number	:	1356347843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE GLENNON EVANS JR. M.D.

Provider Business Mailing Address
First Line	:	3824 WATSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1237
Country	:	US
Telephone Number	:	314-352-4400
Fax Number	:	314-352-8496

Provider Business Practice Location Address
First Line	:	3824 WATSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1237
Country	:	US
Telephone Number	:	314-352-4400
Fax Number	:	314-352-8496

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	07/08/2007

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