Basic Information
Provider Information | |||||||||
NPI: | 1447234356 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COHEN | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11995 SINGLETREE LN | ||||||||
Address2: | SUITE 500 | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553445347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951100 | ||||||||
FaxNumber: | 9529423361 | ||||||||
Practice Location | |||||||||
Address1: | 5104 BRADLEY BLVD | ||||||||
Address2: |   | ||||||||
City: | CHEVY CHASE | ||||||||
State: | MD | ||||||||
PostalCode: | 208156526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951100 | ||||||||
FaxNumber: | 9529423361 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2005 | ||||||||
LastUpdateDate: | 02/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD14295 | DC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0034540 | MD | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 470001526 | 01 |   | RR MEDICARE | OTHER | 300135370 | 01 |   | RR MEDICARE | OTHER | 330581301 | 05 | MD |   | MEDICAID |