Provider Demographics
NPI:1619944931
Name:COULSON, LEWIS RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:RUSSELL
Last Name:COULSON
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 1:3024 W LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1708
Mailing Address - Country:US
Mailing Address - Phone:312-569-6260
Mailing Address - Fax:312-569-6536
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6260
Practice Address - Fax:312-569-6536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine