Provider Demographics
NPI:1356330922
Name:LEWIS CLARK GASTROENTEROLOGY PLLC
Entity Type:Organization
Organization Name:LEWIS CLARK GASTROENTEROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-298-3002
Mailing Address - Street 1:1630 23RD AVE
Mailing Address - Street 2:SUITE 701
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6350
Mailing Address - Country:US
Mailing Address - Phone:208-298-3002
Mailing Address - Fax:208-298-7433
Practice Address - Street 1:1630 23RD AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6350
Practice Address - Country:US
Practice Address - Phone:208-298-3002
Practice Address - Fax:208-298-7433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806979100Medicaid
DC7217Medicare PIN
1377071Medicare PIN
ID806979100Medicaid
DD0649Medicare PIN
DC4935Medicare PIN