Provider Demographics
NPI:1629032594
Name:POWELL, RANDELL G (MD)
Entity Type:Individual
Prefix:
First Name:RANDELL
Middle Name:G
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 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-763-6655
Mailing Address - Fax:954-763-6799
Practice Address - Street 1:1601 S ANDREWS AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-763-6655
Practice Address - Fax:954-763-6799
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50450207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270228200Medicaid
FL03726OtherBCBS
FL03726OtherBCBS
FL270228200Medicaid