Provider Demographics
NPI:1235196965
Name:LEWIS, MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UPPER CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4324
Mailing Address - Country:US
Mailing Address - Phone:443-643-2000
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK547Medicare ID - Type Unspecified
MD489PR165Medicare PIN
Q36204Medicare UPIN
MDR165Medicare PIN