Provider Demographics
NPI:1811018393
Name:POWELL, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 COUNTY ROUTE 84
Mailing Address - Street 2:
Mailing Address - City:TROUPSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915
Practice Address - Country:US
Practice Address - Phone:814-274-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003684L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA081454JT3Medicare ID - Type Unspecified