Basic Information
| Provider Information | |||||||||
| NPI: | 1477599231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEWELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 HOSPITAL DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182127990 | ||||||||
| FaxNumber: | 3182127995 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 HOSPITAL DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182127990 | ||||||||
| FaxNumber: | 3182127995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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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 | 207R00000X | 022107 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1495603 | 05 | LA | MEDICAID |