Healthcare Provider Details

I. General information

NPI: 1194928994
Provider Name (Legal Business Name): ELENA JEAN LEWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 W MILHAM AVE SUITE 1
PORTAGE MI
49024-2239
US

IV. Provider business mailing address

1324 W MILHAM AVE STE 1
PORTAGE MI
49024-2239
US

V. Phone/Fax

Practice location:
  • Phone: 269-342-0196
  • Fax: 269-342-0532
Mailing address:
  • Phone: 269-341-7806
  • Fax: 269-341-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085524
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberEL085524
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: