1154446680 NPI number — DR. SHANTA PEARL HENDERSON POWELL MD

Table of content: DR. SHANTA PEARL HENDERSON POWELL MD (NPI 1154446680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154446680 NPI number — DR. SHANTA PEARL HENDERSON POWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
SHANTA
Provider Middle Name:
PEARL HENDERSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDERSON
Provider Other First Name:
SHANTA
Provider Other Middle Name:
PEARL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154446680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 WADE AVE
Provider Second Line Business Mailing Address:
DAYHOFF B
Provider Business Mailing Address City Name:
CATONSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-4663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-402-7749
Provider Business Mailing Address Fax Number:
410-402-7678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 WADE AVE
Provider Second Line Business Practice Location Address:
DAYHOFF B
Provider Business Practice Location Address City Name:
CATONSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-4663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-402-7749
Provider Business Practice Location Address Fax Number:
410-402-7678
Provider Enumeration Date:
03/21/2007

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: 2084P0804X , with the licence number:  D63367 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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