1689647844 NPI number — TIMOTHY J POWELL MD

Table of content: SUSANA BUCKETT (NPI 1578878138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689647844 NPI number — TIMOTHY J POWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
TIMOTHY
Provider Middle Name:
J
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689647844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2570 NW EDENBOWER BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-6214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-677-7200
Provider Business Mailing Address Fax Number:
541-229-3309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1937 W HARVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-677-7200
Provider Business Practice Location Address Fax Number:
541-229-3309
Provider Enumeration Date:
02/08/2006

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: 207Q00000X , with the licence number:  MD12182 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J406423 . This is a "IND PACSOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 080120961 . This is a "IND RAILROAD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 065847 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000188005 . This is a "IND BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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