1255436093 NPI number — DONALD L POWELL MD

Table of content: DONALD L POWELL MD (NPI 1255436093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255436093 NPI number — DONALD L POWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
DONALD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POWELL
Provider Other First Name:
DONALD
Provider Other Middle Name:
LANGSTON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1255436093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29171-6069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7035 SAINT ANDREWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212-1177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-749-0924
Provider Business Practice Location Address Fax Number:
803-407-4101
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  14016 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LL6884 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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