Provider Demographics
NPI:1750370243
Name:LAWLER-BJORNBERG, COLLEEN M (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:LAWLER-BJORNBERG
Suffix:
Gender:F
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:PO BOX 1431
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-1431
Mailing Address - Country:US
Mailing Address - Phone:618-457-8275
Mailing Address - Fax:618-997-5499
Practice Address - Street 1:1129 N CARBON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1068
Practice Address - Country:US
Practice Address - Phone:618-993-0002
Practice Address - Fax:618-997-5499
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103133Medicaid
IL036103133Medicaid
IL201907Medicare ID - Type Unspecified