Healthcare Provider Details

I. General information

NPI: 1295099174
Provider Name (Legal Business Name): KYLE MICHEAL LEWIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 2200
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3245
  • Fax: 616-391-3130
Mailing address:
  • Phone: 513-245-3107
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301101548
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: