MEDICARE: DR. LAWRENCE B DAMIANI D.O.

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	207RG0100X	Gastroenterology Physician	5101006523	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5101006523	OTHER	MI	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619960010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE B DAMIANI D.O.

Provider Business Mailing Address
First Line	:	3903 HOLLYWOOD RD
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-9149
Country	:	US
Telephone Number	:	269-408-1100
Fax Number	:	269-408-1329

Provider Business Practice Location Address
First Line	:	3903 HOLLYWOOD RD
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-9149
Country	:	US
Telephone Number	:	269-408-1100
Fax Number	:	269-408-1329

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	07/08/2007

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