Healthcare Provider Details

I. General information

NPI: 1073709622
Provider Name (Legal Business Name): JEREMIAH P LEWIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 12/07/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12289 HANCOCK ST STE 34
CARMEL IN
46032-5801
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-815-8950
  • Fax: 317-815-8951
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10000791A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: