Healthcare Provider Details

I. General information

NPI: 1295233617
Provider Name (Legal Business Name): ROGER A LEWIN MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 N CHARLES ST STE 139
TOWSON MD
21204-6829
US

IV. Provider business mailing address

504 CLUB LN
TOWSON MD
21286-7302
US

V. Phone/Fax

Practice location:
  • Phone: 410-828-7045
  • Fax: 410-938-4444
Mailing address:
  • Phone: 410-802-0159
  • Fax: 410-946-8509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0027329
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROGER LEWIN
Title or Position: OWNER
Credential: MD
Phone: 410-828-7045