Provider Demographics
NPI:1619343514
Name:LEWIS, CHARLES SCOTT III
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SCOTT
Last Name:LEWIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11726 ROSEMARY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-1349
Mailing Address - Country:US
Mailing Address - Phone:313-808-5898
Mailing Address - Fax:
Practice Address - Street 1:11726 ROSEMARY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-1349
Practice Address - Country:US
Practice Address - Phone:313-808-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator