Basic Information
| Provider Information | |||||||||
| NPI: | 1164419818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | K.C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1645 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617021645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
| FaxNumber: | 3094545167 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 FORT JESSE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541616 | ||||||||
| FaxNumber: | 3094545167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0360924582 | 05 | IL | MEDICAID |