Basic Information
| Provider Information | |||||||||
| NPI: | 1699744722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | GLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 993 D JOHNSON FERRY RD | ||||||||
| Address2: | STE 440 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042570799 | ||||||||
| FaxNumber: | 4045032280 | ||||||||
| Practice Location | |||||||||
| Address1: | 993 D JOHNSON FERRY RD | ||||||||
| Address2: | STE 440 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042570799 | ||||||||
| FaxNumber: | 4045032280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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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 | 2080P0206X | 052357 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2134940 | 01 | AETNA HMO POS | OTHER | 5433953006 | 01 | CIGNA | OTHER | REF000087396 | 01 | MEDICAID REFERENCE PROVID | OTHER | 000709497H | 01 | MEDICAID PROVIDER NUMBER | OTHER | 52508068010 | 01 | BLUE CHOICE PROVIDER ID | OTHER | 000981901A | 05 | GA | MEDICAID | 5757428 | 01 | AETNA MC PPO PIN NUMBER | OTHER | 1422312 | 01 | UNITED HEALTH CARE | OTHER | 080685 | 01 | BLUE CHOICE FAC INSURANCE | OTHER | 1789 | 01 | KAISER | OTHER |