Provider Demographics
NPI:1669421434
Name:LEWIS, BROOKE HANAWAY (MD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:HANAWAY
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:HANAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2835 BRANDYWINE RD
Mailing Address - Street 2:300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-488-9202
Mailing Address - Fax:678-547-1499
Practice Address - Street 1:134 RIVERSTONE TER STE 202
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1705
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0559512080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA780942438AMedicaid
I30453Medicare UPIN
37BBGWSMedicare ID - Type Unspecified