Basic Information
| Provider Information | |||||||||
| NPI: | 1477525970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDWELL | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 GOVERNORS DR SW FL 1 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358015171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565331600 | ||||||||
| FaxNumber: | 5653908562 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 GOVERNORS DR SW FL 1 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565331600 | ||||||||
| FaxNumber: | 2565390856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA722 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207T00000X | 281802-1 | NY | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 37118 | AL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 216388 | 05 | AL | MEDICAID | 970028451 | 01 | KY | RR MCARE | OTHER | 216728 | 05 | AL | MEDICAID | 000000243993 | 01 | KY | BCBS PIN # | OTHER | 216493 | 05 | AL | MEDICAID | 9500292900 | 05 | KY | MEDICAID |