Provider Demographics
NPI:1669456729
Name:LEWIS, BERRY (MD)
Entity Type:Individual
Prefix:
First Name:BERRY
Middle Name:
Last Name:LEWIS
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 1:9204 S PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5513
Mailing Address - Country:US
Mailing Address - Phone:708-422-4221
Mailing Address - Fax:708-422-4415
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2746
Practice Address - Country:US
Practice Address - Phone:708-422-4221
Practice Address - Fax:708-422-4415
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075439207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA51858Medicare UPIN