Basic Information
| Provider Information | |||||||||
| NPI: | 1306900386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDMUND J LEWIS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72354 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441920002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128291424 | ||||||||
| FaxNumber: | 3128508431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1426 W WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128291424 | ||||||||
| FaxNumber: | 3128508431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALTZBERG | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | NEAL | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3128291424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DR | ||||||||
| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036082043 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01615381 | 01 | IL | BLUECROSS ID # | OTHER | 036082043 | 05 | IL | MEDICAID | 390002208RR | 01 | IL | RAILROAD MC ID# | OTHER |