Provider Demographics
NPI:1255431755
Name:LEWELLEN, GARRETT RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:RUSSELL
Last Name:LEWELLEN
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 1:50 COVE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2514
Mailing Address - Country:US
Mailing Address - Phone:207-828-8777
Mailing Address - Fax:207-828-8778
Practice Address - Street 1:50 COVE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2514
Practice Address - Country:US
Practice Address - Phone:207-828-8777
Practice Address - Fax:207-828-8778
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1311111N00000X
MA2460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022072OtherANTHEM PROVIDER NUMBER
ME1092630OtherAETNA PROVIDER NUMBER
ME55-0850500OtherMARCHIGONNE PROVIDER #
ME8546678OtherCIGNA PROVIDER #
ME55-0850500OtherMEDNET/UHC PROVIDER #
ME1255431755OtherMEDICARE PTAN UX2253
ME351404OtherHARVARD PILGRAM PROVIDER
ME022072OtherANTHEM PROVIDER NUMBER
ME1092630OtherAETNA PROVIDER NUMBER
MEME0370Medicare PIN