Provider Demographics
NPI:1285614503
Name:FANELLY, LAWRENCE JOHN JR (DO)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JOHN
Last Name:FANELLY
Suffix:JR
Gender:M
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:P.O. BOX 1188
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1188
Mailing Address - Country:US
Mailing Address - Phone:419-698-9711
Mailing Address - Fax:419-698-2841
Practice Address - Street 1:2600 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3207
Practice Address - Country:US
Practice Address - Phone:419-696-7216
Practice Address - Fax:419-696-2123
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003344F207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3402510110Medicaid
OH0494924Medicaid
F00680Medicare UPIN
OHFA0518251Medicare ID - Type Unspecified