Provider Demographics
NPI:1558391581
Name:CONCANNON, LAURA LEE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEE
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3048 N WILTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6710
Mailing Address - Country:US
Mailing Address - Phone:773-296-5424
Mailing Address - Fax:733-296-5265
Practice Address - Street 1:3048 N WILTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6710
Practice Address - Country:US
Practice Address - Phone:773-296-5424
Practice Address - Fax:733-296-5265
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH13958Medicare UPIN