Provider Demographics
NPI:1659408029
Name:LEWIS & MCCORRY PC
Entity Type:Organization
Organization Name:LEWIS & MCCORRY PC
Other - Org Name:STANDALE FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:616-453-2429
Mailing Address - Street 1:3863 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4520
Mailing Address - Country:US
Mailing Address - Phone:616-453-2429
Mailing Address - Fax:616-453-8340
Practice Address - Street 1:3863 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-4520
Practice Address - Country:US
Practice Address - Phone:616-453-2429
Practice Address - Fax:616-453-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2675738Medicaid
MI2675756Medicaid
MI2675756Medicaid
MI2675738Medicaid