MEDICARE: SAMUEL L JEWETT III PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	002656	GA

General Provider Information

NPI Number	:	1760436752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL L JEWETT III PA

Provider Business Mailing Address
First Line	:	715 KNIGHT BOTTOM RD SE
Second Line	:
City	:	FAIRMOUNT
State	:	GA
Zip	:	30139-2053
Country	:	US
Telephone Number	:	770-608-9379
Fax Number	:	770-773-3080

Provider Business Practice Location Address
First Line	:	6000 JOE FRANK HARRIS PKWY NW
Second Line	:	SUITE D
City	:	ADAIRSVILLE
State	:	GA
Zip	:	30103-2443
Country	:	US
Telephone Number	:	770-773-9201
Fax Number	:	770-773-3080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	07/08/2007

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