Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | EL085524 | MI |
N | 208000000X | Pediatrician | 4301085524 | MI |
NPI | 1194928994 |
---|---|
Provider Name | Dr. Elena Jean Lewis |
First Address | Portage, MI 49024-2239 |
Second Address | Portage, MI 49024-2239 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2007 |
Last Update Date | 15/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1194928994 | (05) | MI |
700C910950 | BCBSM (01) | MI |