Healthcare Provider Details

I. General information

NPI: 1902892490
Provider Name (Legal Business Name): GARY R LEWISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 EAST MAIN STREET SUITE 105
EAST DUNDEE IL
60118
US

IV. Provider business mailing address

2500 W HIGGINS RD SUITE 505
HOFFMAN ESTATES IL
60169-1642
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-3322
  • Fax:
Mailing address:
  • Phone: 847-843-0806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-066163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: