Basic Information
| Provider Information | |||||||||
| NPI: | 1699717512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COWELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 EASTON AVE | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180174208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106941000 | ||||||||
| FaxNumber: | 6108677180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 207Q00000X | 5101016284 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2199 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS0108721 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2199 | 01 | ME | STATE LICENSE NUMBER | OTHER | 4701167 | 05 | MI | MEDICAID | 0131390 | 01 | MI | IBA HEALTH PLANS | OTHER | 0851222234 | 01 | MI | BCBSM | OTHER | 114701167 | 05 | MI | MEDICAID | 0131390 | 01 | MI | PHP OF SW MICHIGAN | OTHER | KC016284 | 01 | MI | STATE LICENSE NUMBER | OTHER |