Basic Information
| Provider Information | |||||||||
| NPI: | 1043229990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | VAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4381 S EASON BLVD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628405747 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 20824 | MS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | 20824 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07451813 | 05 | MS | MEDICAID |