Healthcare Provider Details

I. General information

NPI: 1396775318
Provider Name (Legal Business Name): EDWARD LEWIS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N MAIN ST
ITHACA MI
48847-1132
US

IV. Provider business mailing address

4449 FASHION SQUARE BLVD
SAGINAW MI
48603-5217
US

V. Phone/Fax

Practice location:
  • Phone: 989-875-4707
  • Fax:
Mailing address:
  • Phone: 989-790-0007
  • Fax: 989-790-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301043453
License Number StateMI

VIII. Authorized Official

Name: EDWARD LEWIS
Title or Position: OWNER
Credential: M.D.
Phone: 989-875-4707