Basic Information
| Provider Information | |||||||||
| NPI: | 1053507731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | STE 227 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378324773 | ||||||||
| FaxNumber: | 9378322986 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | STE 227 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378324773 | ||||||||
| FaxNumber: | 9378322986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35.095562 | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0067275 | 05 | OH | MEDICAID |