Basic Information
| Provider Information | |||||||||
| NPI: | 1912972043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15386 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277040386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194775152 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 PARKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194775152 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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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 | 054586 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 174400000X | 054586 | GA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 130862775C | 05 | GA | MEDICAID | 130862775D | 05 | GA | MEDICAID | 01064795 | 01 | GA | AMERIGROUP | OTHER |