Healthcare Provider Details

I. General information

NPI: 1790770386
Provider Name (Legal Business Name): MARY LOU LEWIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS STREET CAMC
CHARLESTON WV
25301
US

IV. Provider business mailing address

7026 VALLEY BROOK DRIVE
CHARLESTON WV
25312-9460
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7191
  • Fax:
Mailing address:
  • Phone: 304-984-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number9415
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number9415
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: