Provider Demographics
NPI:1912905050
Name:POWELL, ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
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 1:4030 RIVERSIDE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1365
Mailing Address - Country:US
Mailing Address - Phone:478-474-2200
Mailing Address - Fax:478-314-0740
Practice Address - Street 1:4030 RIVERSIDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1365
Practice Address - Country:US
Practice Address - Phone:478-474-2200
Practice Address - Fax:478-314-0740
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19981208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00306545AMedicaid
GA00306545AMedicaid
GA24BCBTMMedicare ID - Type Unspecified