MEDICARE: SAMUEL WATSON LEWIS ATC, PT, DPT

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	2255A2300X	Athletic Trainer	AT003580	GA
2	225100000X	Physical Therapist	PT016070	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15680192	OTHER		CAQH NUMBER

General Provider Information

NPI Number	:	1497216600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL WATSON LEWIS ATC, PT, DPT

Provider Business Mailing Address
First Line	:	33900 HARPER AVE STE 104
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48035-4258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1061 DOWDY RD
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30606-5700
Country	:	US
Telephone Number	:	762-728-4440
Fax Number	:	762-728-4441

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

Provider Enumeration Date	:	03/29/2019
Last Update Date	:	03/09/2026

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