Provider Demographics
NPI:1598095069
Name:POWELL ORTHOPEDICS, PA
Entity Type:Organization
Organization Name:POWELL ORTHOPEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-582-4647
Mailing Address - Street 1:PO BOX 9688
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0030
Mailing Address - Country:US
Mailing Address - Phone:479-582-4647
Mailing Address - Fax:479-582-4660
Practice Address - Street 1:3733 N BUSINESS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5203
Practice Address - Country:US
Practice Address - Phone:479-582-4647
Practice Address - Fax:479-582-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR6372900001Medicare NSC