Healthcare Provider Details

I. General information

NPI: 1801073499
Provider Name (Legal Business Name): DRS BRAD & ELAINE LEWIS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 E MAIN ST
LANCASTER OH
43130-4056
US

IV. Provider business mailing address

1147 E MAIN ST
LANCASTER OH
43130-4056
US

V. Phone/Fax

Practice location:
  • Phone: 740-687-9173
  • Fax: 740-689-3740
Mailing address:
  • Phone: 740-687-9173
  • Fax: 740-689-3740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35056043
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35059549
License Number StateOH

VIII. Authorized Official

Name: MR. MATTHEW T WOLF
Title or Position: CONTRACT/CREDENTIALING MANAGER
Credential: BSBA
Phone: 740-687-5164