Provider Demographics
NPI:1043321326
Name:SEWELL, PATRICK ELLISON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:ELLISON
Last Name:SEWELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E PEACE ST
Mailing Address - Street 2:A
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4938
Mailing Address - Country:US
Mailing Address - Phone:601-832-2643
Mailing Address - Fax:
Practice Address - Street 1:1421 E PEACE ST
Practice Address - Street 2:A
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4938
Practice Address - Country:US
Practice Address - Phone:601-832-2643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS148762085D0003X, 2085R0202X, 2085U0001X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0001X, 2085R0204X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSG31538Medicare UPIN