Provider Demographics
NPI:1073589594
Name:SEWALL, SYDNEY R (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:R
Last Name:SEWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5736
Mailing Address - Country:US
Mailing Address - Phone:207-626-1561
Mailing Address - Fax:207-626-1849
Practice Address - Street 1:15 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5736
Practice Address - Country:US
Practice Address - Phone:207-626-1561
Practice Address - Fax:207-626-1849
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011090208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME288020099Medicaid
MEQX8292Medicare PIN
MEMM256101Medicare PIN
MEE11858Medicare UPIN
MEMM2561Medicare ID - Type Unspecified