Basic Information
| Provider Information | |||||||||
| NPI: | 1588762611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 CARROLL AND TATE STREETS | ||||||||
| Address2: | CALL BOX 3600 | ||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768838000 | ||||||||
| FaxNumber: | 2768894336 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 CARROLL AND TATE STREETS | ||||||||
| Address2: | CALL BOX 3600 | ||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768838000 | ||||||||
| FaxNumber: | 2768894336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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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 | 207P00000X | 0101034533 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1588762611 | 05 | VA | MEDICAID | 64027030 | 05 | KY | MEDICAID |