Basic Information
| Provider Information | |||||||||
| NPI: | 1891779724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | TREVOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3043 | ||||||||
| Address2: | MEA AEA KENOSH SC | ||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605223043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 75TH ST | ||||||||
| Address2: | AURORA MEDICAL CENTER | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531427884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626977000 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 47028020 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036-089750 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34586500 | 05 | WI | MEDICAID |