Provider Demographics
NPI:1386635654
Name:LEWIS, MADELINE ROSE (DO)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:ROSE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:517-353-3050
Mailing Address - Fax:517-432-3742
Practice Address - Street 1:2727 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3488
Practice Address - Country:US
Practice Address - Phone:517-975-3750
Practice Address - Fax:517-975-3755
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001093A207Q00000X
MI5101020162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200048620Medicaid
MI1385535654Medicaid
MI1385535654Medicaid
IN162520MMedicare PIN