Provider Demographics
NPI:1568492940
Name:LEWIS, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:6428 JOLIET RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4646
Mailing Address - Country:US
Mailing Address - Phone:708-352-4448
Mailing Address - Fax:708-352-1052
Practice Address - Street 1:1801 W TAYLOR ST STE 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-996-7416
Practice Address - Fax:312-413-8204
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2018-07-30
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Provider Licenses
StateLicense IDTaxonomies
IL036-072183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363741448OtherTAX ID NUMBER