1689613960 NPI number — DR. MARK G LEWIS DO

Table of content: DR. MARK G LEWIS DO (NPI 1689613960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689613960 NPI number — DR. MARK G LEWIS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
MARK
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1689613960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-364-6253
Provider Business Mailing Address Fax Number:
517-364-6204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 E MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE 345
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-364-6210
Provider Business Practice Location Address Fax Number:
517-364-2842
Provider Enumeration Date:
06/05/2006

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: 174400000X , with the licence number:  02000903A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 02000903A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100325730B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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