Provider Demographics
NPI:1124083365
Name:LAWRENCE-FRIEDL, DARYL M (DO)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:M
Last Name:LAWRENCE-FRIEDL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 FOREST HILL AVE., SE,
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2380
Mailing Address - Country:US
Mailing Address - Phone:616-954-0402
Mailing Address - Fax:616-954-0404
Practice Address - Street 1:877 FOREST HILL AVE., SE,
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2380
Practice Address - Country:US
Practice Address - Phone:616-954-0402
Practice Address - Fax:616-954-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010305207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1639382211Medicaid
MIDH2054OtherRR MEDICARE
MI0D12216OtherBCBS GROUP
MI0D12216OtherBCBS GROUP
MI1639382211Medicaid