Provider Demographics
NPI:1275585713
Name:LEWIS, COREY BLAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:BLAINE
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:P.O. BOX 256
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64069-2233
Mailing Address - Country:US
Mailing Address - Phone:816-968-9320
Mailing Address - Fax:
Practice Address - Street 1:2750 CLAY EDWARDS DR. STE. 200A
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116
Practice Address - Country:US
Practice Address - Phone:816-968-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005027554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207529207Medicaid
36109027OtherBCBS OF KC INDIVIDUAL
I48842Medicare UPIN
MOM78000007Medicare PIN