Provider Demographics
NPI:1457374183
Name:MCEWAN, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MCEWAN
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 1:5039 SWAMP RD
Mailing Address - Street 2:SUITE 401, PO BOX 417
Mailing Address - City:FOUNTAINVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18923-9667
Mailing Address - Country:US
Mailing Address - Phone:215-230-8380
Mailing Address - Fax:215-230-8370
Practice Address - Street 1:5039 SWAMP RD
Practice Address - Street 2:SUITE 401
Practice Address - City:FOUNTAINVILLE
Practice Address - State:PA
Practice Address - Zip Code:18923-9667
Practice Address - Country:US
Practice Address - Phone:215-230-8380
Practice Address - Fax:215-230-8370
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045494L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG74790Medicare UPIN
PA098327HYLMedicare ID - Type Unspecified