Provider Demographics
NPI:1568691186
Name:JENNIFER M. LEWISTON
Entity Type:Organization
Organization Name:JENNIFER M. LEWISTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LEWISTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-709-1177
Mailing Address - Street 1:42536 HAYES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3644
Mailing Address - Country:US
Mailing Address - Phone:586-286-9644
Mailing Address - Fax:
Practice Address - Street 1:42536 HAYES RD STE 100
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3644
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII18667Medicare UPIN