Provider Demographics
NPI:1275878019
Name:POWDERLY, WILLIAM G (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:POWDERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-9098
Mailing Address - Fax:314-362-9851
Practice Address - Street 1:620 S TAYLOR AVE
Practice Address - Street 2:DIV IM INFECTIOUS DISEASE, STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1035
Practice Address - Country:US
Practice Address - Phone:314-362-9098
Practice Address - Fax:314-362-9851
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013003690207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202535316Medicaid
ILENROLLEDMedicaid