Healthcare Provider Details

I. General information

NPI: 1023334919
Provider Name (Legal Business Name): ANDREW BENNETT SEWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1156
US

IV. Provider business mailing address

21000 E 12 MILE RD STE 111
SAINT CLAIR SHORES MI
48081-1156
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-7610
  • Fax: 586-779-0031
Mailing address:
  • Phone: 586-779-7610
  • Fax: 586-779-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301503576
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number4301503576
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: