Provider Demographics
NPI:1497726251
Name:POWELL, JAMES S (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:S
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 1:6 WHITE FANG DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1397
Mailing Address - Country:US
Mailing Address - Phone:618-288-0938
Mailing Address - Fax:618-288-0938
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:DEPT. OF ANESTHESIOLOGY
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015447207L00000X
IL036111788207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207401001Medicaid
MO931950325Medicare PIN
MOI33191Medicare UPIN