Provider Demographics
NPI:1669406286
Name:POWDERLY, FINBAR GERARD (M D)
Entity type:Individual
Prefix:
First Name:FINBAR
Middle Name:GERARD
Last Name:POWDERLY
Suffix:
Gender:M
Credentials:M D
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 489
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:WV
Mailing Address - Zip Code:26150-0489
Mailing Address - Country:US
Mailing Address - Phone:304-489-1222
Mailing Address - Fax:304-489-1285
Practice Address - Street 1:1578 ELIZABETH PIKE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:WV
Practice Address - Zip Code:26150-8413
Practice Address - Country:US
Practice Address - Phone:304-489-1222
Practice Address - Fax:304-489-1285
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0056452001Medicaid
WV0056452001Medicaid
WV8803932Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
1669406286Medicare PIN