Provider Demographics
NPI:1124091913
Name:POWELL, ALLEN O (MD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:O
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 3179
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3179
Mailing Address - Country:US
Mailing Address - Phone:855-381-8191
Mailing Address - Fax:855-286-0486
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-745-1200
Practice Address - Fax:270-843-5020
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY307722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64307721Medicaid
KY0943420Medicare ID - Type Unspecified
KY64307721Medicaid