Provider Demographics
NPI:1538166160
Name:LEWIS, LARRY S (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:S
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 1:1414 W/ FAIR AVENUE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3853
Mailing Address - Fax:906-228-4065
Practice Address - Street 1:1414 W FAIR AVENUE
Practice Address - Street 2:SUITE 230
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3853
Practice Address - Fax:906-228-4065
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILL042094208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1944751Medicaid
MI0E26017OtherBLUE CROSS/BLUE SHIELD
020E26017004Medicare PIN
MI0E26017OtherBLUE CROSS/BLUE SHIELD
MI0E26017Medicare ID - Type UnspecifiedMEDICARE
MIC85144Medicare UPIN