Provider Demographics
NPI:1508194309
Name:JOHN A. POWELL DERMATOLOGY, LTD
Entity Type:Organization
Organization Name:JOHN A. POWELL DERMATOLOGY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. MEDICAL PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-863-7080
Mailing Address - Street 1:1034 SO. BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 1160
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1258
Mailing Address - Country:US
Mailing Address - Phone:314-863-7080
Mailing Address - Fax:314-863-1540
Practice Address - Street 1:1034 SO. BRENTWOOD BLVD
Practice Address - Street 2:SUITE 1160
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1258
Practice Address - Country:US
Practice Address - Phone:314-863-7080
Practice Address - Fax:314-863-1540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6721207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000004280Medicare PIN
A11080Medicare UPIN