Provider Demographics
NPI:1871676650
Name:LEWIS, SAM R (DC)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 S. R. 43
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4354
Mailing Address - Country:US
Mailing Address - Phone:330-422-1551
Mailing Address - Fax:330-422-1553
Practice Address - Street 1:9304 S. R. 43
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4354
Practice Address - Country:US
Practice Address - Phone:330-422-1551
Practice Address - Fax:330-422-1553
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000213133OtherANTHEM PIN #
OH341973070-00OtherBWC ID #
OH000000213133OtherANTHEM PIN #