Provider Demographics
NPI:1417976150
Name:POWELL, GUY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:ROBERT
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 1:1155 N. MAYFAIR RD.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:414-456-5990
Mailing Address - Fax:
Practice Address - Street 1:1155 N. MAYFAIR RD.
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3421
Practice Address - Country:US
Practice Address - Phone:414-456-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34267400Medicaid
WI34267400Medicaid
WI011102905Medicare PIN
H70284Medicare UPIN