Provider Demographics
NPI:1467457135
Name:POWERS FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:POWERS FAMILY PRACTICE PC
Other - Org Name:THOMAS J POWERS MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-855-4224
Mailing Address - Street 1:1810 MESQUITE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5886
Mailing Address - Country:US
Mailing Address - Phone:928-855-4224
Mailing Address - Fax:928-855-5114
Practice Address - Street 1:1810 MESQUITE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:928-855-4224
Practice Address - Fax:928-855-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2007-09-21
Deactivation Date:2007-05-30
Deactivation Code:
Reactivation Date:2007-08-21
Provider Licenses
StateLicense IDTaxonomies
AZAZ18959305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
E23934Medicare UPIN
AZZ76174Medicare ID - Type UnspecifiedPRACTICE ID
AZZ76175Medicare ID - Type UnspecifiedDOCTOR ID