Healthcare Provider Details

I. General information

NPI: 1891779724
Provider Name (Legal Business Name): TREVOR LEWIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 75TH ST AURORA MEDICAL CENTER
KENOSHA WI
53142-7884
US

IV. Provider business mailing address

PO BOX 3043 MEA AEA KENOSH SC
OAK BROOK IL
60522-3043
US

V. Phone/Fax

Practice location:
  • Phone: 262-697-7000
  • Fax: 630-734-1560
Mailing address:
  • Phone: 630-734-0200
  • Fax: 630-734-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number47028020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-089750
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: