1104864321 NPI number — GREGORY M LEWIS M.D.

Table of content: GREGORY M LEWIS M.D. (NPI 1104864321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104864321 NPI number — GREGORY M LEWIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
GREGORY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104864321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 S FRONTAGE RD
Provider Second Line Business Mailing Address:
SUITE 325
Provider Business Mailing Address City Name:
WOODRIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60517-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-789-3422
Provider Business Mailing Address Fax Number:
630-789-9093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 N ELM ST STE 404
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINSDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60521-3638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-789-3422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036-075101 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 036075101 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IL4174011 . This is a "MEDICARE-LOCALITY 16" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL4177011 . This is a "MEDICARE-LOCALITY 15" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1912218850 . This is a "NPI GROUP PRACTICE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".