Provider Demographics
NPI:1154316222
Name:POWELL, MATTHEW NEIL (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NEIL
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5933 GRAND HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-6011
Mailing Address - Country:US
Mailing Address - Phone:231-799-3300
Mailing Address - Fax:231-799-3322
Practice Address - Street 1:5933 GRAND HAVEN RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-6011
Practice Address - Country:US
Practice Address - Phone:231-799-3300
Practice Address - Fax:231-799-3322
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4309931Medicaid
MI0N31120Medicare ID - Type Unspecified
MI4309931Medicaid