Provider Demographics
NPI:1457445579
Name:LEWIS, ERNEST C (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:C
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:PO BOX 13453
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3453
Mailing Address - Country:US
Mailing Address - Phone:920-432-6049
Mailing Address - Fax:920-884-3271
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46104207RX0202X
MI4301082745207RX0202X
MO2008020485207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104541760Medicaid
AR172426001Medicaid
WI34436200Medicaid
MOP00635672OtherTRAVELERS RR MEDICARE
MIEL082745OtherBCBS MI
MO132680013Medicare PIN
MOP00635672OtherTRAVELERS RR MEDICARE
MO132300010Medicare PIN
WI000807071Medicare ID - Type Unspecified
MIEL082745OtherBCBS MI
MIM84790008Medicare ID - Type Unspecified