Provider Demographics
NPI:1659500130
Name:JONATHAN D. LEWIS MD SC
Entity Type:Organization
Organization Name:JONATHAN D. LEWIS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-271-8345
Mailing Address - Street 1:4753 N BROADWAY ST
Mailing Address - Street 2:SUITE 830
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5266
Mailing Address - Country:US
Mailing Address - Phone:773-271-8345
Mailing Address - Fax:773-275-0318
Practice Address - Street 1:4753 N BROADWAY ST
Practice Address - Street 2:SUITE 830
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5266
Practice Address - Country:US
Practice Address - Phone:773-271-8345
Practice Address - Fax:773-275-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36053771251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL649490Medicare PIN