MEDICARE: LEWIS R COLLINS JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	034795	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5257583	OTHER	GA	BLUE CROSS BLUE SHIELD GA

General Provider Information

NPI Number	:	1679669840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEWIS R COLLINS JR. MD

Provider Business Mailing Address
First Line	:	1013 E 1ST ST
Second Line	:
City	:	VIDALIA
State	:	GA
Zip	:	30474-4227
Country	:	US
Telephone Number	:	912-538-7702
Fax Number	:	912-538-9520

Provider Business Practice Location Address
First Line	:	4849 PAULSEN ST
Second Line	:	SUITE 300
City	:	SAVANNAH
State	:	GA
Zip	:	31405-4423
Country	:	US
Telephone Number	:	912-354-7546
Fax Number	:	912-354-7558

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	06/20/2023

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