Provider Demographics
NPI:1558657635
Name:LEWIS, HERBERT ANDERSON IV (MD)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:ANDERSON
Last Name:LEWIS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DREW
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1808 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:479-444-7820
Practice Address - Street 1:ST MARY'S HOSPITALIST GROUP
Practice Address - Street 2:1808 W MAIN ST
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-964-4178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7839207P00000X, 208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199346001Medicaid
293483YJFXMedicare PIN