Healthcare Provider Details

I. General information

NPI: 1386635654
Provider Name (Legal Business Name): MADELINE ROSE LEWIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 S PENNSYLVANIA AVE
LANSING MI
48910-3488
US

IV. Provider business mailing address

401 S BALLENGER HWY
FLINT MI
48532-3638
US

V. Phone/Fax

Practice location:
  • Phone: 517-975-3750
  • Fax: 517-975-3755
Mailing address:
  • Phone: 517-353-3050
  • Fax: 517-432-3742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001093A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101020162
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: