Basic Information
| Provider Information | |||||||||
| NPI: | 1528089612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEWELL | ||||||||
| FirstName: | MYRON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 HAVERFORD AVE. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191391401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154712761 | ||||||||
| FaxNumber: | 2154726093 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 HAVERFORD AVE. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191391401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154712761 | ||||||||
| FaxNumber: | 2154726093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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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 | MD031348E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA04169400 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009858110 | 05 | PA | MEDICAID | 00548140000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 009858110002 | 05 | PA | MEDICAID |