1144432402 NPI number — BRIAN KEITH POWELL DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144432402 NPI number — BRIAN KEITH POWELL DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

POWELL

Provider First Name:

BRIAN

Provider Middle Name:

KEITH

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

M

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:

1144432402

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/06/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 10549

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ST PETERSBURG

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33733-0549

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

727-824-8181

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

12420 130TH AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

LARGO

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33774-1919

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

727-824-8181

Provider Business Practice Location Address Fax Number:

727-587-7739

Provider Enumeration Date:

05/07/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  5101016675 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207Q00000X , with the licence number: OS12134 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 080G310660 . This is a "BCBS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 381908328-435 . This is a "CARE SOURCE OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 1144432402 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 381908328 . This is a "PRIORITY HEALTH OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 176125 . This is a "GREAT LAKES HEALTH PLAN OF MI" identifier . This identifiers is of the category "OTHER".
• Identifier: 01019633 . This is a "HEALTH PLUS OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 080G310660 . This is a "BLUE CARE NETWORK OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 008859000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 1053717 . This is a "MCLAREN HEALTH PLAN/HEALTH ADVANTAGE" identifier . This identifiers is of the category "OTHER".
• Identifier: 1144432402 . This is a "MOLINA HEALTHCARE OF MICHIGAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 381908328 . This is a "AETNA UNDER" identifier . This identifiers is of the category "OTHER".
• Identifier: 54684 . This is a "HEALTH PLAN OF MICHIGAN" identifier . This identifiers is of the category "OTHER".