Healthcare Provider Details

I. General information

NPI: 1144253410
Provider Name (Legal Business Name): LEWIS C HALVERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DE PAUL DR STE 315
BRIDGETON MO
63044-2514
US

IV. Provider business mailing address

220 COMPASS POINT DR
SAINT CHARLES MO
63301-4405
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-5858
  • Fax:
Mailing address:
  • Phone: 636-947-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036078330
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036078330
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberR1J93
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR1J93
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: