Healthcare Provider Details

I. General information

NPI: 1760563373
Provider Name (Legal Business Name): JACK K LEWIS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 89TH ST SUITE 101
OMAHA NE
68114-4072
US

IV. Provider business mailing address

220 N 89TH ST SUITE 101
OMAHA NE
68114-4072
US

V. Phone/Fax

Practice location:
  • Phone: 402-393-3616
  • Fax: 402-393-4347
Mailing address:
  • Phone: 402-393-3616
  • Fax: 402-393-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10515
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number778
License Number StateNE

VIII. Authorized Official

Name: JACK K LEWIS
Title or Position: PRESIDENT
Credential: MD
Phone: 402-393-3616