Provider Demographics
NPI:1841381191
Name:JAMES ROBERT POWELL, MD PLLC
Entity Type:Organization
Organization Name:JAMES ROBERT POWELL, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:631-431-5288
Mailing Address - Street 1:60 BUCCANEER LN
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1968
Mailing Address - Country:US
Mailing Address - Phone:631-431-5288
Mailing Address - Fax:631-675-0692
Practice Address - Street 1:60 BUCCANEER LN
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1968
Practice Address - Country:US
Practice Address - Phone:631-431-5288
Practice Address - Fax:631-675-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02109406Medicaid
NYWANA61Medicare PIN
NY02109406Medicaid