Provider Demographics
NPI:1730530148
Name:MANN, LEWIS T (MD)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:T
Last Name:MANN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:420 NE GLEN OAK AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:400 JOHN DEERE RD BLDG 2
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6898
Practice Address - Country:US
Practice Address - Phone:309-517-3036
Practice Address - Fax:309-797-1088
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2025-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IAR-10643207R00000X
IAMD-47669207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036155111Medicaid
IA2504957Medicaid