1457445579 NPI number — ERNEST C LEWIS M.D.

Table of content: ERNEST C LEWIS M.D. (NPI 1457445579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457445579 NPI number — ERNEST C LEWIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
ERNEST
Provider Middle Name:
C
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:
1457445579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13453
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54307-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-432-6049
Provider Business Mailing Address Fax Number:
920-884-3271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 S FREMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-8099
Provider Business Practice Location Address Fax Number:
417-820-8093
Provider Enumeration Date:
10/03/2006

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: 207RX0202X , with the licence number:  46104 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X , with the licence number: 4301082745 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: 2008020485 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 104541760 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 172426001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34436200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00635672 . This is a "TRAVELERS RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: EL082745 . This is a "BCBS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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