1265469738 NPI number — AUGUSTINE WARNER LEWIS III

Table of content: AUGUSTINE WARNER LEWIS III (NPI 1265469738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265469738 NPI number — AUGUSTINE WARNER LEWIS III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
AUGUSTINE
Provider Middle Name:
WARNER
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
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:
1265469738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7864 RICHMOND TAPPAHANNOCK HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AYLETT
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23009-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-746-1677
Provider Business Mailing Address Fax Number:
804-769-3170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7864 RICHMOND TAPPAHANNOCK HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AYLETT
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23009-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-746-1677
Provider Business Practice Location Address Fax Number:
804-769-3170
Provider Enumeration Date:
06/28/2006

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: 207Q00000X , with the licence number:  0101019901 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C05698 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 204502 . This is a "ANTHEM (BC/BS OF VA)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 254728 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5606468 . This is a "AETNA - LIFE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5606468 . This is a "AETNA - HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 005811694 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080123285 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1471267 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 79134 . This is a "SOUTHERN HEALTH SERVICES" identifier . This identifiers is of the category "OTHER".




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