Provider Demographics
NPI:1871677005
Name:LEWIS, ALBERT W
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:W
Last Name:LEWIS
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 1:1305 ASH ST
Mailing Address - Street 2:P O BOX 102
Mailing Address - City:BRIDGEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:62417-1707
Mailing Address - Country:US
Mailing Address - Phone:618-945-5858
Mailing Address - Fax:618-945-5313
Practice Address - Street 1:1305 ASH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:IL
Practice Address - Zip Code:62417-1707
Practice Address - Country:US
Practice Address - Phone:618-945-5858
Practice Address - Fax:618-945-5313
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5 5232341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371386411001Medicaid
IL551380Medicare ID - Type UnspecifiedAMBULANCE SERVICE