Provider Demographics
NPI:1437216710
Name:POWELL MEDICAL CENTER MINISTISTRIES INC
Entity Type:Organization
Organization Name:POWELL MEDICAL CENTER MINISTISTRIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-4471
Mailing Address - Street 1:515 PIERRE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-2445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 PIERRE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-2445
Practice Address - Country:US
Practice Address - Phone:318-221-4471
Practice Address - Fax:318-221-4913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL012949305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1140376Medicaid
LA1140376Medicaid
LAB61121Medicare UPIN