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General NPI Number Information
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NPI Number | 1194928994
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Entity Type | Individual
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Provider Name | ELENA JEAN LEWIS MD
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Gender | Female
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Dates
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Enumeration Date | 06/08/2007
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Last Update Date | 12/15/2016
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Provider Practice Location Address
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Address Line | 1324 W MILHAM AVE SUITE 1
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City | PORTAGE
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State | MI
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Zip | 49024-2239
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Country | US
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Telephone | 269-342-0196
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Fax | 269-342-0532
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Provider Business Mailing Address
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Address Line | 1324 W MILHAM AVE STE 1
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City | PORTAGE
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State | MI
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Zip | 49024-2239
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Country | US
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Telephone | 269-341-7806
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Fax | 269-341-8743
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 4301085524
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | EL085524
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License Number State | MI
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