Basic Information
| Provider Information | |||||||||
| NPI: | 1104854421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | EDMUND | ||||||||
| MiddleName: | GEOFFREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748905 | ||||||||
| FaxNumber: | 3526748901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 SANTA BARBARA BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526741740 | ||||||||
| FaxNumber: | 3526748940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12136 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME117287 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 12136 | MS | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME117287 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 753068151015 | 01 | MS | TRICARE | OTHER | 168390708 | 01 | DOL | OTHER | 00015124 | 05 | MS | MEDICAID |