Provider Demographics
NPI:1326032665
Name:SEWELL, JACK BITTELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BITTELL
Last Name:SEWELL
Suffix:
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-0468
Mailing Address - Country:US
Mailing Address - Phone:610-956-0003
Mailing Address - Fax:
Practice Address - Street 1:901 E SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2833
Practice Address - Country:US
Practice Address - Phone:662-846-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME229712085R0202X
MS053202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL134262411OtherTAX ID
FL58248OtherBCBS
FLP00041336OtherMEDICARE RR
FL134262411OtherTAX ID
FL58248OtherBCBS