1245215573 NPI number — DR. SCOTT G LEWIS M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245215573 NPI number — DR. SCOTT G LEWIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
SCOTT
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
1245215573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29992 NORTHWESTERN HWY STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-3292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-851-1430
Provider Business Mailing Address Fax Number:
248-851-5182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32255 NORTHWESTERN HWY STE 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48334-1573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-355-9323
Provider Business Practice Location Address Fax Number:
248-355-9232
Provider Enumeration Date:
12/09/2005

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: 207R00000X , with the licence number:  4301046235 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1245215573 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700F314390 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C4706 . This is a "M'CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0630659 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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