Basic Information
| Provider Information | |||||||||
| NPI: | 1275751778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT 457 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017587888 | ||||||||
| FaxNumber: | 9013875153 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 EASTMORELAND AVE | ||||||||
| Address2: | SUITE 370 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017587888 | ||||||||
| FaxNumber: | 9013875153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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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 | 208600000X | MD45085 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1514518 | 05 | TN | MEDICAID | 4355671 | 01 | TN | BCBS | OTHER | 03239711 | 05 | MS | MEDICAID | 178398001 | 05 | AR | MEDICAID |