Basic Information
| Provider Information | |||||||||
| NPI: | 1700861739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEWITT | ||||||||
| FirstName: | E | ||||||||
| MiddleName: | CAMERON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEWITT | ||||||||
| OtherFirstName: | EDRA | ||||||||
| OtherMiddleName: | CAMERON | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042971780 | ||||||||
| FaxNumber: | 4042527255 | ||||||||
| Practice Location | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042971780 | ||||||||
| FaxNumber: | 4042527255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 057082 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0012X | 057082 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1130048 | 01 | GA | AETNA | OTHER | 804593303A | 05 | GA | MEDICAID | 804593303B | 05 | GA | MEDICAID | 804593303P | 05 | GA | MEDICAID | 804593303D | 05 | GA | MEDICAID | 804593303C | 05 | GA | MEDICAID | 804593303O | 05 | GA | MEDICAID | 52704119 | 01 | GA | BCBS OF GEORGIA | OTHER |