1861695892 NPI number — MS. COLETTE E LEE-LEWIS MD

Table of content: MS. COLETTE E LEE-LEWIS MD (NPI 1861695892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861695892 NPI number — MS. COLETTE E LEE-LEWIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE-LEWIS
Provider First Name:
COLETTE
Provider Middle Name:
E
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1861695892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3025 SHRINE RD
Provider Second Line Business Mailing Address:
STE 270
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-262-2723
Provider Business Mailing Address Fax Number:
877-244-5666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3025 SHRINE RD
Provider Second Line Business Practice Location Address:
STE 270
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-262-2723
Provider Business Practice Location Address Fax Number:
877-244-5666
Provider Enumeration Date:
06/07/2007

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: 207RN0300X , with the licence number:  055783 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 630423104A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01035668 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00215034 . This is a "RILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52043977 . This is a "BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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