MEDICARE: LEONARD A LEWIS JR. D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101009918	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174581300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONARD A LEWIS JR. D.O.

Provider Business Mailing Address
First Line	:	3863 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-4520
Country	:	US
Telephone Number	:	616-453-2429
Fax Number	:	616-453-8340

Provider Business Practice Location Address
First Line	:	3863 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-4520
Country	:	US
Telephone Number	:	616-453-2429
Fax Number	:	616-453-8340

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	03/28/2008

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