Basic Information
| Provider Information | |||||||||
| NPI: | 1043220643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5500 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | 9033266461 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035252992 | ||||||||
| FaxNumber: | 9035921934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 01/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | E8826 | TX | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RI0011X | E8826 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 752616977053 | 01 | TX | TRICARE LOCAL CODE (530) | OTHER |