Healthcare Provider Details

I. General information

NPI: 1568492940
Provider Name (Legal Business Name): MARY E. LEWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612
US

IV. Provider business mailing address

6428 JOLIET RD SUITE 201
LA GRANGE HIGHLANDS IL
60525-4646
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7416
  • Fax: 312-413-8204
Mailing address:
  • Phone: 708-352-4448
  • Fax: 708-352-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-072183
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: