Provider Demographics
NPI:1447360029
Name:JEWETT, BRYAN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:EDWARD
Last Name:JEWETT
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2684
Practice Address - Country:US
Practice Address - Phone:262-670-4000
Practice Address - Fax:262-670-4091
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49857208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136UTMedicaid
WI34737300Medicaid
NC2027236Medicare ID - Type Unspecified
NC89136UTMedicaid
WI019940588Medicare PIN