Provider Demographics
NPI:1891707642
Name:POWELL, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
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:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-0526
Mailing Address - Country:US
Mailing Address - Phone:270-527-2411
Mailing Address - Fax:270-527-8734
Practice Address - Street 1:619 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5094
Practice Address - Country:US
Practice Address - Phone:270-527-2411
Practice Address - Fax:270-527-8734
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2705272411OtherOFFICE PHONE
KY34554OtherKY STATE LIC
KY64345648Medicaid
TN4047220Medicaid
KY0935614Medicare PIN