Provider Demographics
NPI:1487747481
Name:RAINES, LAWRENCE ALAN (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALAN
Last Name:RAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 EASTLAND DR
Mailing Address - Street 2:STE 104
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:309-663-4351
Mailing Address - Fax:309-663-8359
Practice Address - Street 1:1404 EASTLAND DR
Practice Address - Street 2:STE 104
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:309-663-4351
Practice Address - Fax:309-663-8359
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360571721Medicaid
C45652Medicare UPIN
IL0360571721Medicaid