Provider Demographics
NPI:1164523932
Name:POWELL, JAMES GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GREGORY
Last Name:POWELL
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 1:415 SOUTH 28TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-296-2780
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:5909 US HIGHWAY 49
Practice Address - Street 2:SUITE 30
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-296-2780
Practice Address - Fax:601-296-2781
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17911207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572TBOtherAMERICAN ADMIN GROUP
MS07358051Medicaid
MSP00022157OtherRAILROAD MEDICARE
MS460000015Medicare PIN
MS640507572TBOtherAMERICAN ADMIN GROUP