Provider Demographics
NPI:1215919543
Name:LEWIS, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5217
Mailing Address - Country:US
Mailing Address - Phone:989-790-0007
Mailing Address - Fax:989-790-7547
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1132
Practice Address - Country:US
Practice Address - Phone:989-875-6849
Practice Address - Fax:989-875-6870
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1875064Medicaid
0290030OtherBCBSM
MI233858Medicare Oscar/Certification
02900306022Medicare ID - Type Unspecified
0290030OtherBCBSM
MIA45474Medicare UPIN
MI233850Medicare Oscar/Certification