Provider Demographics
NPI:1215000518
Name:LEWIS, RODGER P (MD)
Entity Type:Individual
Prefix:DR
First Name:RODGER
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5403
Mailing Address - Country:US
Mailing Address - Phone:731-885-9231
Mailing Address - Fax:731-884-1967
Practice Address - Street 1:1201 BISHOP ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5403
Practice Address - Country:US
Practice Address - Phone:731-885-9231
Practice Address - Fax:731-884-1967
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000007577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2005923 & 104944OtherBLUE CROSS PROVIDER NUMBE
TN2005923 & 104944OtherBLUE CROSS PROVIDER NUMBE
TN3401246 & 3156203Medicare ID - Type UnspecifiedPROVIDER NUMBER