Provider Demographics
NPI:1477629749
Name:LEWIS, MARK R (MPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 CAMDEN ST STE 401
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2421
Mailing Address - Country:US
Mailing Address - Phone:207-593-6682
Mailing Address - Fax:207-213-1075
Practice Address - Street 1:91 CAMDEN ST STE 401
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2421
Practice Address - Country:US
Practice Address - Phone:207-593-6682
Practice Address - Fax:207-213-1075
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME206502AMedicare ID - Type UnspecifiedPHYSICAL THERAPY
ME1235215070Medicaid