Provider Demographics
NPI:1760563373
Name:JACK K LEWIS MD PC
Entity Type:Organization
Organization Name:JACK K LEWIS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-393-3616
Mailing Address - Street 1:220 N 89TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4072
Mailing Address - Country:US
Mailing Address - Phone:402-393-3616
Mailing Address - Fax:402-393-4347
Practice Address - Street 1:220 N 89TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4072
Practice Address - Country:US
Practice Address - Phone:402-393-3616
Practice Address - Fax:402-393-4347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10515207R00000X
NE778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026059900Medicaid
NE10026059900Medicaid