Basic Information
| Provider Information | |||||||||
| NPI: | 1114912797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWELLEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1740 NICHOLASVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592606970 | ||||||||
| FaxNumber: | 8592606649 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 NICHOLASVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592606970 | ||||||||
| FaxNumber: | 8592606649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 02835 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VX0000X | 02835 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 64077936 | 05 | KY | MEDICAID |