MEDICARE: DR. BRADLEY W LEWIS D.C.

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	111N00000X	Chiropractor	038005756	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	950F329750	OTHER	MI	BCBS OF MI PROVIDER ID

General Provider Information

NPI Number	:	1750328456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY W LEWIS D.C.

Provider Business Mailing Address
First Line	:	4015 N ROCKWELL ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3720
Country	:	US
Telephone Number	:	773-706-2580
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 N ROCKWELL ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3720
Country	:	US
Telephone Number	:	773-706-2580
Fax Number	:

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	03/27/2013

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