Provider Demographics
NPI:1821284506
Name:WASSERMAN, LEWIS
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004408213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01703994OtherRAILROAD MEDICARE
ILP01458509OtherRAILROAD MEDICARE
WI1821284506Medicaid
ILP01458509OtherRAILROAD MEDICARE
WIK400319705Medicare PIN