Provider Demographics
NPI:1255367025
Name:LEWIS, RUSSELL JR (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:LEWIS
Suffix:JR
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 1:900 ILLINOIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-346-5000
Mailing Address - Fax:
Practice Address - Street 1:190 GRAND SEASONS DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-8219
Practice Address - Country:US
Practice Address - Phone:715-258-3650
Practice Address - Fax:715-258-5749
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4937420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34867900Medicaid
WI34867900Medicaid
007069135Medicare PIN