Provider Demographics
NPI:1740462878
Name:JERRY R. POWELL, M.D.
Entity type:Organization
Organization Name:JERRY R. POWELL, M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:765-675-8733
Mailing Address - Street 1:239 ASH ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-1752
Mailing Address - Country:US
Mailing Address - Phone:765-675-8733
Mailing Address - Fax:765-675-7121
Practice Address - Street 1:239 ASH ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-1752
Practice Address - Country:US
Practice Address - Phone:765-675-8733
Practice Address - Fax:765-675-7121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053633332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200914960AMedicaid
IN200914960AMedicaid
IN1467634584Medicare PIN
IN1740462878Medicare PIN