Basic Information
Provider Information | |||||||||
NPI: | 1326035072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | BETH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1303 AZALEA CT | ||||||||
Address2: | STE C | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295775765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436920570 | ||||||||
FaxNumber: | 8434979566 | ||||||||
Practice Location | |||||||||
Address1: | 555 E CHEVES ST | ||||||||
Address2: | RADIOLOGY DEPARTMENT | ||||||||
City: | FLORENCE | ||||||||
State: | SC | ||||||||
PostalCode: | 295062617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436695162 | ||||||||
FaxNumber: | 8436674573 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2005 | ||||||||
LastUpdateDate: | 09/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 26702 | SC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 890067F4 | 01 | NC | NC MEDICAID | OTHER | 154758900 | 01 | SC | US DEPT OF LABOR | OTHER | P00116458 | 01 | SC | RAILROAD MEDICARE | OTHER | 570525838 | 01 | SC | STANDARD TAX ID | OTHER | 067F4 | 01 | NC | BCBS OF NC | OTHER | 267026 | 05 | SC |   | MEDICAID | D4050 | 01 | SC | MEDCOST | OTHER | 154758900 | 01 | SC | FEDERAL BLACK LUNG | OTHER |