Basic Information
Provider Information | |||||||||
NPI: | 1518942176 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POWELL | ||||||||
FirstName: | ARTHUR | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28625 NORTHWESTERN HWY | ||||||||
Address2: | SUITE 243 | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480341828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483582310 | ||||||||
FaxNumber: | 2483520734 | ||||||||
Practice Location | |||||||||
Address1: | 28625 NORTHWESTERN HWY | ||||||||
Address2: | SUITE 243 | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480341828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483582310 | ||||||||
FaxNumber: | 2483520734 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2005 | ||||||||
LastUpdateDate: | 02/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301059204 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | C44319 | 01 | MI | M'CARE | OTHER | 1518942176 | 05 | MI |   | MEDICAID | 700F314390 | 01 | MI | BLUE SHIELD | OTHER | 0631032 | 01 | MI | BCBS INDIVIDUAL | OTHER |