Basic Information
| Provider Information | |||||||||
| NPI: | 1003010976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | BRANDI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ALEXANDER | ||||||||
| OtherFirstName: | BRANDI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1180 ERNEST W BARRETT PKWY NW STE 102B | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301444534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783542273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1180 ERNEST W BARRETT PKWY NW STE 102B | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783542273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35.094508 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | E-10688 | AR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 76750 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 221871001 | 05 | AR | MEDICAID |