Basic Information
| Provider Information | |||||||||
| NPI: | 1821104480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAWRENCE | ||||||||
| OtherFirstName: | H. | ||||||||
| OtherMiddleName: | STEVEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 LAKESIDE AVE E | ||||||||
| Address2: | #1200 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441141158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1260 INDEPENDENCE AVE | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443101812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165247377 | ||||||||
| FaxNumber: | 3306304275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
| 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 | 208000000X | 35-052066 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0643996 | 05 | OH | MEDICAID |